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In this European Public Health news, health is put at the centre of society as it is impacting us from birth until death. Jakab emphasizes the importance of investing in health over the life-course, whilst McKee demonstrates that the whole society impacts health. A strong, unified health care system and seeing healthy people as the cornerstone of healthy economies is the key message in the contribution by Andriukaitis, the newly elected EU Commissioner for Health and Food Safety. Making the voice of public health visible, both nationally and internationally and facilitating a strong and unified voice is what Zeegers and Barnhoorn see as the core activities of EUPHA and the EPH Conference Foundation. # President's Column {#article-title-2} A new year is a time for both reflection and anticipation. Reflection on what has gone well, or not so well in the past year and anticipation of the challenges and opportunities we will face in the year ahead. For EUPHA, we have much to celebrate from the past year and much to look forward to in 2015. In my last column, I wrote about our conference in Glasgow, where a combination of excellent organization and outstanding content created an event that will be remembered for many years. Now we are looking forward to Milan, with a programme that promises to be every bit as imaginative and informative. One of the streams will be on communication and advocacy in public health, something that I am particularly looking forward to, given its importance in making the world a better place. We have a new President Elect, Natasha Muscat, who is already making an invaluable contribution to our work, stimulating our thinking about how we can take EUPHA to ever greater heights. We also have a new website and logo, two things among many for which we are grateful …

The adoption of the 2030 Agenda for Sustainable Development in 2015 opened new opportunities to work towards healthy environments through ‘whole of government’ and ‘whole of society’ approaches. It created a strong policy platform that acknowledges health as a result and an enabler of sustainable policies across all sectors of government. Five years into the process, an initial analysis of emerging trends indicates that, despite some encouraging developments in policy as well as overall progress in economy and technology, there remains a gap between rhetoric, ambition and reality. In particular, the monitoring system for environment and health-related sustainable development goals (SDGs) and targets requires further development; inequalities in environment and health persist and in some areas have increased; equity is not yet a central element of implementation and reporting on the achievement of the SDGs; and, most worrying of all, trends in key environmental indicators that are vital to the survival of the human species, such as those related to climate change and biodiversity, are still on an overall negative path. In summary, governments must significantly and rapidly increase action to secure the habitability and safety of planet Earth. The public health community assumes an unprecedented role in placing and maintaining health and equity at the heart of the political agenda. This demands new governance models conferring on the health sector a clear mandate and legitimacy to operate across sectors. It also requires enhancing capacities among health professionals to embrace this new level of complexity, understand the multiple links between sectoral policies and health, and successfully engage with other government sectors and stakeholders.

Active travel (walking or cycling for transport) is considered the most sustainable form of personal transport. Yet its net effects on mobility-related CO2 emissions are complex and underresearched. Here we collected travel activity data in seven European cities and derived life cycle CO2 emissions across modes and purposes. Daily mobility-related life cycle CO2 emissions were 3.2 kgCO(2) per person, with car travel contributing 70% and cycling 1%. Cyclists had 84% lower life cycle CO2 emissions than non-cyclists. Life cycle CO2 emissions decreased by 14% per additional cycling trip and decreased by 62% for each avoided car trip. An average person who `shifted travel modes' from car to bike decreased life cycle CO2 emissions by 3.2 kgCO(2)/day. Promoting active travel should be a cornerstone of strategies to meet net zero carbon targets, particularly in urban areas, while also improving public health and quality of urban life. This work was supported by the European project Physical Activity through Sustainable Transportation Approaches (PASTA). PASTA (http://www.pastaproject.eu/) was a four-year project funded by the European Union's Seventh Framework Program (EU FP7) under European Commission - Grant Agreement No. 602624. CB is also supported by UK Research and Innovation (UKRI) under the Centre for Research on Energy Demand Solutions (CREDS, Grant agreement number EP/R035288/1). ED is also supported by a postdoctoral scholarship from FWO - Research Foundation Flanders. ML held a joint PASTA/VITO PhD scholarship. SS is supported by the Martin Filko Scholarship from the Ministry of Education in Slovakia. Brand, C (corresponding author), Univ Oxford, Transport Studies Unit, South Parks Rd, Oxford OX, christian.brand@ouce.ox.ac.uk

Active travel (walking or cycling for transport) is considered the most sustainable and low carbon form of getting from A to B. Yet the net effects of changes in active travel on changes in mobility-related CO 2 emissions are complex and under-researched. Here we collected longitudinal data on daily travel behavior, journey purpose, as well as personal and geospatial characteristics in seven European cities and derived mobility-related lifecycle CO 2 emissions over time and space. Statistical modelling of longitudinal panel (n = 1849) data was performed to assess how changes in active travel, the 'main mode' of daily travel, and cycling frequency influenced changes in mobility-related lifecycle CO 2 emissions. We found that changes in active travel have significant lifecycle carbon emissions benefits, even in European urban contexts with already high walking and cycling shares. An increase in cycling or walking consistently and independently decreased mobility-related lifecycle CO 2 emissions, suggesting that active travel substituted for motorized travel-i.e. the increase was not just additional (induced) travel over and above motorized travel. To illustrate this, an average person cycling 1 trip/day more and driving 1 trip/day less for 200 days a year would decrease mobility-related lifecycle CO 2 emissions by about 0.5 tonnes over a year, representing a substantial share of average per capita CO 2 emissions from transport. The largest benefits from shifts from car to active travel were for business purposes, followed by social and recreational trips, and commuting to work or place of education. Changes to commuting emissions were more pronounced for those who were younger, lived closer to work and further to a public transport station. Even if not all car trips could be substituted by active travel the potential for decreasing emissions is considerable and significant. The study gives policy and practice the empirical evidence needed to assess climate change mitigation impacts of urban transport measures and interventions aimed at mode shift to more sustainable modes of transport. Investing in and promoting active travel whilst 'demoting' private car ownership and use should be a cornerstone of strategies to meet 'net zero' carbon targets, particularly in urban areas, while also reducing inequalities and improving public health and quality of urban life in a post-COVID-19 world. This work was supported by the European project Physical Activity through Sustainable Transportation Approaches (PASTA). PASTA (http://www.pastaproject.eu/) was a four-year project funded by the European Union’s Seventh Framework Program (European Commission Grant Agreement No. 602624). CB also gratefully acknowledges support from UK Research and Innovation through the UK Energy Research Centre (grant reference number EP/S029575/1). ED is also supported by a postdoctoral scholarship from FWO – Research Foundation Flanders. ML held a joint PASTA/VITO PhD scholarship. SS is supported by the Martin Filko Scholarship from the Ministry of Education in Slovakia

The World Health Organization&rsquo, s Health Economic Assessment Tool (HEAT) for walking and cycling is a user-friendly web-based tool to assess the health impacts of active travel. HEAT, developed over 10 years ago, has been used by researchers, planners and policymakers alike in appraisals of walking and cycling policies at both national and more local scales. HEAT has undergone regular upgrades adopting the latest scientific evidence. This article presents the most recent upgrades of the tool. The health impacts of walking and/or cycling in a specified population are quantified in terms of premature deaths avoided (or caused). In addition to the calculation of benefits derived from physical activity, HEAT was recently expanded to include assessments of the burden associated with air pollution exposure and crash risks while walking or cycling. Further, the impacts on carbon emissions from mode shifts to active travel modes can now be assessed. The monetization of impacts using Value of Statistical Life and Social Costs of Carbon now uses country-specific values. As active travel inherently results in often substantial health benefits as well as not always negligible risks, assessments of active travel behavior or policies are incomplete without considering health implications. The recent developments of HEAT make it easier than ever to obtain ballpark estimates of health impacts and carbon emissions related to walking and cycling.

Active travel (walking or cycling for transport) is considered the most sustainable form of getting from A to B. Yet the net effects of active travel on mobility-related CO2 emissions are complex and under-researched. Here we collected travel activity data in seven European cities and derived lifecycle CO2 emissions from daily travel activity. Daily mobility-related lifecycle CO2 emissions were 3.2 kgCO2 per person, with car travel contributing 70% and cycling 1%. Cyclists had 84% lower lifecycle CO2 emissions from all daily travel than non-cyclists. Lifecycle CO2 emissions decreased by -14% (95%CI -12% to -16%) per additional cycling trip and decreased by -62% (95%CI -61% to -63%) for each avoided car trip. An average person who ‘shifted travel modes’ from car to bike decreased lifecycle CO2 emissions by 3.2 (95%CI 2.0 to 5.2) kgCO2/day, and using a bike as the ‘main method of travel’ gave 7.1 (95%CI 4.8 to 10.4) kgCO2/day lower lifecycle CO2 emissions than mainly using a car or van. Investing in and promoting active travel should be a cornerstone of strategies to meet net zero carbon targets, particularly in urban areas, while also improving public health and quality of urban life.

Adequate funding, careful planning, and good governance are central to delivering quality research in any field. Yet, the strategic directions for research, the mechanisms through which topics emerge, and the priorities assigned are equally deserving of attention. The need to understand the role played by the environment and to manage the physical environment and the human activities which bear upon it in pursuit of health, well-being, and equity are long established. These imperatives drive environmental health research as a key branch of scientific inquiry. Targeted research over many years, applying established methods, has informed society’s understanding of the toxic, infectious, allergenic, and physical threats to health from our physical surroundings and how these may be managed. Essentially hazard-focused research continues to deliver policy-relevant findings while simultaneously posing questions to be addressed through further research. Environmental health in the 21st century is, however, confronted by additional challenges of a rather different character. These include the need to understand, in a better and more policy-relevant way, the contributions of the environment to health and equity in complex interaction with other societal and individual-level influences (a so-called socioecological model). Also important are the potential of especially green and blue natural environments to improve health and well-being and promote equity, and the health implications of new approaches to production and consumption, such as the circular economy. Such challenges add breadth, depth, and richness to the environmental health research agenda, but when combined with the existential and public health threat of humanity’s detrimental impact on the Earth’s systems, they entail a need for new and better strategies for scientific inquiry. As we confront the challenges and uncertainties of the Anthropocene, the complexity expands, the stakes become sky-high, and diverse interests and values clash. Thus, the pressure on environmental health researchers to evolve and engage with stakeholders and reach out to the widest constituency of policy and practice has never been greater, nor has the need to organize to deliver. A disparate range of contextual factors have become pertinent when scoping the now significantly extended, territory for environmental health research. Moreover, the challenges of prioritizing among the candidate topics for investigation have scarcely been greater.

The health economic assessment tool (HEAT) for walking and cycling has been developed as a user-friendly yet robust tool for transport and urban planners allowing the inclusion of physical activity benefits in transport appraisals. The most recent version can now also consider how much road crashes and air pollution affect these results, and what the effects on carbon emissions are. The HEAT process adheres to an agreed set of key principles and a standardized, iterative process for updates. An assessment consists of five steps that are described in this chapter. The HEAT has been used widely, and three practical applications in different settings are presented to illustrate possible uses and ways of disseminating the results.

BACKGROUND: In the fight against rising overweight and obesity levels, and unhealthy urban environments, the renaissance of active mobility (cycling and walking as a transport mode) is encouraging. Transport mode has been shown to be associated to body mass index (BMI), yet there is limited longitudinal evidence demonstrating causality. We aimed to associate transport mode and BMI cross-sectionally, but also prospectively in the first ever European-wide longitudinal study on transport and health. METHODS: Data were from the PASTA project that recruited adults in seven European cities (Antwerp, Barcelona, London, Oerebro, Rome, Vienna, Zurich) to complete a series of questionnaires on travel behavior, physical activity levels, and BMI. To assess the association between transport mode and BMI as well as change in BMI we performed crude and adjusted linear mixed-effects modeling for cross-sectional (n = 7380) and longitudinal (n = 2316) data, respectively. RESULTS: Cross-sectionally, BMI was 0.027 kg/m2 (95%CI 0.015 to 0.040) higher per additional day of car use per month. Inversely, BMI was -0.010 kg/m2 (95%CI -0.020 to -0.0002) lower per additional day of cycling per month. Changes in BMI were smaller in the longitudinal within-person assessment, however still statistically significant. BMI decreased in occasional (less than once per week) and non-cyclists who increased cycling (-0.303 kg/m2, 95%CI -0.530 to -0.077), while frequent (at least once per week) cyclists who stopped cycling increased their BMI (0.417 kg/m2, 95%CI 0.033 to 0.802). CONCLUSIONS: Our analyses showed that people lower their BMI when starting or increasing cycling, demonstrating the health benefits of active mobility. ispartof: ENVIRONMENT INTERNATIONAL vol:119 pages:109-116 ispartof: location:Netherlands status: published

Purpose Cycling and walking is a promising approach to counteract some of the leading risk factors for Europe’s health, including physical inactivity, air pollution and climate change. The Health E...

Introduction. Exposure to unhealthy living and working conditions is a determinant of health inequity, underlining interactions between environment and socioeconomic development. Environmental degr...

Although sport promotion may play an important role in achieving the recommended levels of physical activity for health, until now, there has been no comprehensive assessment of how sport policies in Europe address health. This article aimed at filling this gap by reviewing and analyzing recent national policy developments in the area of sport promotion, with a focus on synergies and discrepancies with the promotion of health-enhancing physical activity. By applying various search methods, 130 documents focusing on sport and physical activity were identified in the World Health Organization (WHO) European Region. An analysis grid covering key indicators was developed for a systematic content analysis of 25 documents, selected according to established criteria. Analysis showed that general recommendations for good policy making were followed, such as establishing general goals, specifying time frame and responsible body for implementation and addressing different target groups. Furthermore, all sport strategies addressed health on an overall level and recognized the importance of Sport for All. However, in several strategies, there was a lack of measurable targets, specified budgets, and evaluation plans. The analysis showed that there is a great opportunity for health and sport sectors to work more closely together in the future, and identified areas where this could take place.

OBJECTIVE: To review and assess the quality of economic evaluation studies on injury prevention measures. DESIGN: Systematic review. DATA SOURCES: Electronic databases searched included Medline (Pubmed), EMBASE, Web of Science, PsycINFO, and Safetylit. INCLUSION CRITERIA: Empirical studies published in English in international peer-reviewed journals in the period 1998-2009. The subject of the study was economic evaluation of prevention of unintentional injury. Cost-effectiveness (CEA), cost-benefit (CBA) and cost utility (CUA) analyses were included. METHODS: Methodological details, study designs, and analysis and interpretation of results of the included articles were reviewed and extracted into summary tables. Study quality was judged using the criteria recommended by the Panel on cost-effectiveness in health and medicine and the British Medical Journal (BMJ) checklist for economic evaluations. RESULTS: Forty-eight studies met the inclusion criteria of our review. Interventions assessed most frequently were hip protectors and exercise programs for the elderly. A wide variety of methodological approaches was found, including differences in type of economic evaluation, perspective, time horizon, study design, cost categories, effect outcomes, and adjustments for timing and uncertainty used. The majority of studies performed a cost-effectiveness analysis from a societal perspective with a time horizon of one to five years, in which the effect was expressed in terms of injuries prevented and only direct health care costs were included. Most studies deviated from one or more of the Panel recommendations or BMJ guidelines; e.g. not adopting the societal perspective, not including all relevant costs, no incremental analysis. CONCLUSIONS: This review has shown that approaches to economic evaluation of injury prevention vary widely and most studies do not fulfill methodological rigour. Improving quality and harmonization of economic evaluation studies in the field of injury prevention is needed. One way of achieving this would be to establish international guidelines on economic evaluation for injury prevention interventions, based on established economic evaluation checklists, to assist researchers in the design and reporting of economic evaluations. Language: en

Background There is increasing evidence that active mobility contributes to overall physical activity, and is negatively associated with obesity. However, the associations between active mobility, physical activity and body weight are complex. In the current analysis, a number of research gaps are tackled (e.g. including leisure-time physical activity, ensuring a balanced and large enough sample size for different transport modes, a multicentre study in European cities). Methods The PASTA project recruited over 10,000 adults in 7 European cities (Antwerp, Barcelona, London, Oerebro, Rome, Vienna, Zurich) to complete a questionnaire on how they move around the city, their levels of physical activity, and sociodemographics. Self-reported use of different transport modes (“How often do you currently use each of the following methods of travel to get to and from places?”) was operationalized in eight categories: car, bike, e-bike, walk, bike and walk, motorcycle/moped, public transport, mixed. BMI was the dependent variable in multivariate linear regression models; models were sex-stratified; and city was included as random effect. Dominant transport mode was the primary exposure variable; daily car drivers were selected as the reference category. A number of important confounders were included in the analysis: age, days per week of moderate leisure physical activity, education level, household income, alcohol use, smoking, and self-rated health. Results The final sample size for the cross-sectional analysis was 10,562 (54% female, age 40 ± 13). In the models linking transport mode and BMI, we observed stronger relationships in men. A male daily cyclist versus a male daily car driver has a BMI that is on average 1.26 (95%CI 0.64-1.89) points lower, equivalent to 4 kg in our sample. For women, the difference was smaller and not statistically significant: 0.54 BMI points (95%CI -0.14-1.22) or 1.5 kg. In the full sample, we observed the largest difference in BMI for active modes (walking, cycling, and a combination) compared to daily car drivers, and a smaller difference for public transport (-0.58 BMI points; 95%CI -1.01-(-0.16)). People that combine active modes with motorized modes still have a lower BMI compared to only car drivers (-0.33 BMI points; 95%CI -0.79-0.13). Conclusions Men who drive cars as their main form of transport are on average 4kg heavier than those who cycle. In the future, we plan to investigate causality in a longitudinal study design by including results from a follow-up questionnaire reassessing BMI 1-2 years later in the same sample.

Background:Over the past years there has been increasing interest in physical activity promotion and the development of appropriate policy. So far, there has been no comprehensive overview of the activities taking place in Europe in this area of public health policy.Methods:Using different search methods, 49 national policy documents on physical activity promotion were identified. An analysis grid covering key features was developed for the analysis of the 27 documents published in English.Results:Analysis showed that many general recommendations for policy developments are being followed, for example: general goals were formulated, an implementation plan was included, a timeframe and a responsible body for the implementation was often specified. However, limited evidence for intersectoral collaboration was found. Quantified goals for physical activity were the exception. Population groups most in need such as people with low levels of physical activity were rarely specifically targeted. Most policies emphasized the importance of an evaluation. However, only about half of them indicated a related intention or requirement.Conclusion:In recent years there has been a noticeable development of national policy documents on physical activity promotion. Following principles for policy development more closely could increase the effectiveness of their preparation and implementation further.

Injuries, whether intentional or unintentional, are the third leading cause of death in the WHO European Region and pose a threat to economic and social development. Comprehensive policies for injury prevention are a means of organising the actions of different stakeholders and sectors towards achieving the shared objective of preventing injuries. In Europe, the development of comprehensive national policies is advocated by both the WHO Regional Committee resolution EUR/RC55/R9 and the European Council Recommendation on the prevention of injuries and promotion of safety. This article presents an overview of progress achieved by European Member States in implementing these policy recommendations, and some more general reflection on the challenges and opportunities faced in preventing injuries and violence in the Europe. Much progress has been made, with the development of national policies for preventing individual types of injury and violence ranging from 86% for road safety to about one third for preventing youth violence and self-inflicted violence. Countries were assessed as to whether they were implementing any of 69 evidence-based injury and violence prevention programmes selected from the literature. Progress in implementing these varied in different countries, and the median was 56% for the 31 responding countries taken together. Although overall encouraging progress is taking place, the health sector needs to commit more to the widespread implementation of effective programmes, and to engage with other stakeholders in a multisectoral response to prevent injuries. This should include the development of an overarching strategic framework for action, as well as the development of strong evidence-based arguments towards making injury prevention a compelling case for policy makers to act upon, particularly in view of the large gap in safety inequality uncovered by research.

Since the 1980s, the 53 Member States of the European Region of WHO have been engaged in a process involving ministries of health and ministries of environment, aimed at identify priorities and pol...

Summary Injuries cause 9% of deaths and 14% of ill health in the WHO European Region. This problem is neglected; injuries are often seen as part of everyday life. However, although western Europe has good safety levels, death and disability from injury are rising in eastern Europe. People in low-to-middle-income countries in the Region are 3·6 times more likely to die from injuries than those in high-income countries. Economic and political change have led to unemployment, income inequalities, increased traffic, reduced restrictions on alcohol, and loss of social support. Risks such as movement of vulnerable populations and transfer of lifestyles and products between countries also need attention. In many countries, the public-health response has been inadequate, yet the cost is devastating to individuals and health-service budgets. More than half a million lives could be saved annually in the Region if recent knowledge could be used to prevent injuries and thus redress social injustice in this area.

There has been a world-wide increase in scientific interest in health-enhancing physical activity (HEPA). The importance of a physically active lifestyle has now been well established both on the individual and on the population level. At the same time, physical inactivity has become a global problem. While sports for all has a long history, only a few examples of long-term integrated physical activity promotion strategies have been in place in Europe until recently, namely in Finland, the Netherlands and England. A number of countries have now begun to develop their own activities. However, there has been a noticeable lack of a platform for sharing the development and implementation of evidence-based policies and strategies. In order to fill this gap, HEPA Europe, the European Network for the Promotion of Health-Enhancing Physical Activity, was founded in May 2005 in Gerlev, Denmark. The goal of the network is to strengthen and support efforts and actions that increase participation in physical activity and improve the conditions favourable to a healthy lifestyle, in particular with respect to HEPA. The Network is working closely with the WHO Regional Office for Europe (http://www.euro.who.int/hepa). The network focuses on population-based approaches for the promotion of HEPA, using the best-available scientific evidence, and is currently implementing its first projects. HEPA Europe has established collaboration with EU Commission projects and Agita Mundo. Priorities for future work have been defined, and interested organisations and institutions have the opportunity to join the network and participate in the process.

Urban settings play a major role in facilitating and enabling healthy lifestyle choices. In particular, they can provide opportunities for maintaining or reintroducing walking and cycling as part of daily life, contributing to more physically active lifestyles and reducing obesity and risks for important diseases such as coronary heart disease, hypertension, and diabetes. This paper describes analytical tools that can be used locally to support walking and cycling as cost-effective and healthy options for urban mobility. The paper highlights recent international policy developments that are raising awareness of health promoting opportunities provided by walking and cycling, and the role to be played by urban and transport planning in creating favourable conditions for safe walking and cycling. (A)

Purpose Because many emerging economies lack local capacity for scientific research, capacity building has become a priority for many international development organizations. This article describes and critiques an approach used for building local capacity for applied health research in Azerbaijan, one of the newly independent states (NIS) of the former USSR. Methods In 2000, environmental epidemiology training courses were conducted in Azerbaijan. Several local participants of these courses received hands-on training in the planning and conduct of a subsequent cancer study as a practical extension of the training exercises. Results The research demonstrated that international collaboration can not only result in the successful completion of health research in NIS such as Azerbaijan, but also impart research knowledge and experience to local experts. Several practical issues were encountered in the conduct of the training activities that limited their effectiveness. The most desired result (the proposal and conduct of new research by local experts trained through these exercises) has yet to be achieved to the levels expected. Conclusions International collaborations such as the approach described here are useful for imparting expertise to researchers in less affluent countries. However, comprehensive capacity building programs providing ongoing professional development, support, and an enabling environment, rather than scientific training alone, are required to achieve long-term sustainability and measurable outcomes.

This article is a summary of the main findings of the study “Riding towards the green economy: cycling and green jobs”, which was developed in the context of the Transport, Health and Environment pan-European Programme (THE PEP). It builds on previous work under THE PEP, which demonstrated the job creation potential of cycling and of green and healthy transport more generally. The report summarized in this article collected data on jobs associated with cycling directly from city authorities and analysed these to re-assess previous estimates of the job creation potential of cycling. It concluded that the number of cycling-related jobs in the pan-European Region could increase by 435,000 in selected major cities if they increased their cycling share to that of the Danish capital Copenhagen. The implications and potential role of municipal and sub-national authorities in facilitating cycling while supporting economic development are then discussed. These findings indicate that investment in policies that promote cycling could deliver not only important benefits for health, the environment and the quality of urban life, but could also contribute to a sizable creation of job opportunities. Authorities need to be proactive in promoting cycling in order to deliver these benefits.

Background Physical inactivity is the fourth leading cause of global mortality. Hence, the Physical Activity through Sustainable Transport Approaches (PASTA) study aims to promote active mobility (i.e. walking and cycling) as an innovative measure to increase physical activity levels. Studying the health benefits of an increase in active mobility is challenging as we lack understanding of its relation with overall physical activity. Therefore, we studied the association between changes in overall physical activity level and changes in the amount of active mobility and leisure-time physical activity. Methods A set of online questionnaires was deployed in seven European cities to collect data on travel and physical activity behaviour. After completing a baseline questionnaire, follow-up questionnaires were sent every thirteen days, alternating a short and a longer version (every third follow-up). The amount of total and domain-specific (i.e. transport and leisure-time) physical activity was reported in the Global Physical Activity Questionnaire (GPAQ) (separating cycling and walking for transport). The GPAQ was incorporated in the baseline questionnaire and the longer version of the follow-up. To analyse the association between a change in overall physical activity and a change in active mobility and leisure-time physical activity, a mixed effect model was used. This model included sex, age and season as covariates and all interaction terms for active mobility and leisure-time physical activity. We used random participant effects nested in city effects to account for repeated measures. Results 3083 participants completed at least two GPAQs. The maximum number of GPAQs collected per participant was 14 and the median amount of time between two questionnaires was 51 days (IQR:44-86 days). A one-minute increase in daily active mobility or leisure-time physical activity was associated with an increase of 1.14 (p 0.05), so participants who increased their active mobility did not decrease their leisure-time physical activity accordingly. Changes in overall physical activity were not affected by sex, age and season (p>0.05). However, the increase in total physical activity per unit increase in active mobility depended on sex (p Conclusions Our findings provide evidence that an increase in active mobility translated into an increase in overall physical activity, while the amount of leisure-time physical activity was not modified.

Background: Motorized traffic may discourage people walking. This study analyses the influence of motorization on pedestrian mobility in the neighbourhoods of a European city, controlling for environmental, socio-demographic, mobility and road safety characteristics of the neighbourhood in which each trip was made. Methods: Cross-sectional ecological study using the 38 neighbourhoods of Barcelona as the unit of analysis. Mobility information was obtained from the 2006 Daily Mobility Survey. Walking rates were calculated for 32.343 men and women who made walking trips, per 1000 men and women who made trips in the 38 neighbourhoods. Data were aggregated to calculate the total number of motorized trips made in each neighbourhood. beta coefficients and their confidence intervals were calculated using Poisson regression, in order to study the relationship between walking and motorization, in the different tertiles of motorization and adjusting for contextual factors and their corresponding interactions with motorization. Results: Levels of motorization in the neighbourhood negatively influence walking, even when environmental variables of the neighbourhood are considered. In men we observe a gradient whereby walking rates fall as motorization rises (beta = -0.248; P < 0.001 and beta = -0.363; P < 0.001 in the second and third quartiles of motorization, respectively). In the case of women we find that only high levels of motorization have a negative influence on the rates of women who walk. (beta = -0.256; P < 0.001). Conclusion: Motorized traffic discourages people walking. Motorization is a modifiable environment-related factor which should be taken into account when designing policies to promote safe active travel.

As injuries can happen in any setting, to anyone and at any time, the preventive responses required need to be comprehensive. Accordingly, this requires the involvement of many stakeholders from di...

Injuries both unintentional and intentional are a leading cause of death and in the 53 countries of the WHO European region there were an estimated 790 000, accounting for 9% of deaths from all cau...

Background Health impact assessment (HIA) is a combination of methods by which a policy or intervention may be assessed and judged for its potential effects on the health of the population. The HIA is classified in four levels of depth: desk-based, rapid, intermediate and comprehensive. These different levels vary in resources, capacity, duration and level of health impacts. Comprehensive HIA is the more complex, collecting and analyzing data from different sources. It also offers more accurate estimates of the health impacts related with multiple pathways and health determinants. PASTA (Physical Activity through Sustainable Transport Approaches) is a European project with detailed case studies in seven cities (Antwerp, Barcelona, London, Orebro, Rome, Vienna and Zurich) that focuses on promoting and assessing active travel and developing a new comprehensive health impact assessment (HIA) model for active transport. Methods Identifying stakeholders and experts in each city. conduct workshops (one in each city) with stakeholders and experts. Perform individual interviews (12 in each city) with experts and stakeholders. Conduct a systematic review on active travel HIA, risk assessments and cost benefits analysis published in peer review journals. Conduct systematic reviews to identify the most robust epidemiological evidence between health exposures and outcomes. Build a HIA model quantifying the health risk and benefits related with active travel interventions and measure the uncertainties. Report and communicate the results to stakeholders, experts and citizens. Results The workshops and interviews showed their importance to identify 1) main interventions or policies on active travel in the local context; 2) the requirements, priorities and expectations of HIA in the decision making process; 3) local and regional data sources; and 4) key stakeholder networks for participation and dissemination. The systematic review of HIA showed that there is further improvement needed in 1) the identification and quantification of health determinants (e.g. physical activity, traffic hazards, air pollution, noise, etc.); 2) selection of robust dose-response functions based on the weight of evidence; 3) the harmonization of methods, definitions and assumptions used; and 4) the close collaboration between urban planners, transport practitioners and health experts. Conclusions The novel approach of integrating stakeholder and expert workshops, interviews, systematic reviews and evidence based approaches in the HIA process is a necessary advancement for comprehensive HIA for active travel.

Street-vended foods and beverages, an integral part of urban economies in the developing world, have been implicated in cholera transmission in Latin America. To improve the microbiologic quality of market-vended beverages in Guatemala, we tested a simple system consisting of dilute bleach (4.95% free available chlorine) for water purification, narrow-mouth plastic vessels with spigots for disinfecting and storing water and for preparing and storing beverages, handwashing soap, and education in using the system. We conducted a randomized controlled intervention trial among 41 vendors who received the intervention and 42 control vendors, comparing total and fecal coliform bacteria and Escherichia coli contamination of market-vended beverages, stored water, and vendors' hands. Samples were obtained at baseline and at each of six weekly follow-up visits. At baseline, fecal coliform bacteria were found in 40 (48%) market-vended beverages and E. coli in 14 (17%). When compared with samples from control vendors, a significant decrease in total coliform (P < 0.001) and fecal coliform (P < 0.001) bacteria in samples of stored water and beverages sold by intervention vendors was observed over the course of the study. The vessel system was well accepted by vendors. This simple inexpensive system consisting of hypochlorite disinfectant, plastic vessels, soap, and education can significantly reduce fecal contamination of market-vended beverages.

Objectives: The authors designed an instrument to measure objectively aspects of the built and food environments in urban areas, the EURO-PREVOB Community Questionnaire, within the EU-funded project 'Tackling the social and economic determinants of nutrition and physical activity for the prevention of obesity across Europe' (EURO-PREVOB). This paper describes its development, reliability, validity, feasibility and relevance to public health and obesity research. Study design: The Community Questionnaire is designed to measure key aspects of the food and built environments in urban areas of varying levels of affluence or deprivation, within different countries. The questionnaire assesses (1) the food environment and (2) the built environment. Methods: Pilot tests of the EURO-PREVOB Community Questionnaire were conducted in five to 10 purposively sampled urban areas of different socio-economic status in each of Ankara, Brno, Marseille, Riga, and Sarajevo. Inter-rater reliability was compared between two pairs of fieldworkers in each city centre using three methods: inter-observer agreement (IOA), kappa statistics, and intraclass correlation coefficients (ICCs). Results: Data were collected successfully in all five cities. Overall reliability of the EURO-PREVOB Community Questionnaire was excellent (inter-observer agreement (IOA) > 0.87; intraclass correlation coefficients (ICC)s > 0.91 and kappa statistics > 0.7. However, assessment of certain aspects of the quality of the built environment yielded slightly lower IOA coefficients than the quantitative aspects. Conclusions: The EURO-PREVOB Community Questionnaire was found to be a reliable and practical observational tool for measuring differences in community-level data on environmental factors that can impact on dietary intake and physical activity. The next step is to evaluate its predictive power by collecting behavioural and anthropometric data relevant to obesity and its determinants. © 2013 The Royal Society for Public Health.

Background: We aimed to quantify the number of women and men, in Catalonia, among those not achieving physical activity recommendations, making short motorized trips which could have been made on foot, and to estimate the annual economic benefit due to reducing mortality as a result of replacing one short, daily, motorized journey with walking. Methods: Cross-sectional study. Mobility data came from individuals >17 years who reported, in the 2006 Daily Mobility Survey, having travelled on the referred working day (N=80 552). The health economic assessment tool for walking (HEAT) from the World Health Organization (WHO) Regional Office for Europe was used to calculate the economic benefit. Results: Of those not meeting recommendations, 15.6% of men (95% CI 15.2-16.1) and 13.9% of women (95% CI 13.5-14.4) would go on to meet them if they were to replace at least one short motorized trip per day by walking. If applied to the entire population of Catalonia, this change would increase up to 326 557 men (95% CI 313 373-339 740) and up to 252 509 women (95% CI 240 855264 163) who would achieve recommendations through walking rather than driving. According to HEAT estimations, this would suppose a saving of (sic)124 216 000 (95% CI 120 182 000-128 250 000) in men and (sic)84 927 000 (95% CI 81 774 000-88 079 000) in women, derived from the reduction in mortality gained from walking accumulated over one year. Conclusion: This study demonstrates the potential of trips on foot as a source of physical activity. It also points out that both benefits for the health of the population and a huge economic benefit could have been gained through active transportation interventions.

A field monitoring program was carried out on the sewage of five large apartment blocks in the city of Parma, Italy, to verify under realistic conditions existing laboratory data and model calculations on organohalogen formation by domestic hypochlorite (NaOCl) bleach usage. The average adsorbable organic halogens (AOX) level was determined for three distinct experimental phases: an “undisturbed period,” a “no bleach period,” and a “controlled bleach usage period.” The study involved participation of the site inhabitants in the second and third phases. In line with what could be predicted from the hypochlorite chemistry, an effect of the use of hypochlorite bleach on the AOX concentration in domestic sewage was detected. In a laboratory simulation conducted in parallel with the field study, the degree of NaOCl-to-AOX conversion ranged from 0.75 to 2.25% (w/w). The degree of conversion in the field study itself was of the order of 1.5% (or 0.075% when expressed for a typical bleach product containing 5% NaOCl). Under the specific conditions of the site, the difference in average AOX concentration in sewage between the “no bleach” and the “undisturbed” bleach use period was of the order of 37 μg·1−1 (P < 0.05). The average bleach-related AOX emission at the study site was around 7 mg·(inhabitant·day)−1. Overall, these figures correspond well with existing literature data. Linking the measured amounts of AOX with available ecotoxicity data for treated domestic effluents and their organohalogen constituents, it can be considered unlikely that the organohalogens formed by domestic bleaching will exert or trigger any adverse environmental effect.

Background “Health in all policies (HiAP) is an approach to public policies across sectors that systematically takes into account the health and health systems implications of decisions, seeks synergies and avoids harmful health impacts, in order to improve population health and health equity” (Health in all policies – Seizing opportunities, implementing policies. Copenhagen: WHO Regional Office for Europe; 2013). Description of the problem Drawing from the HiAP approach, a “safety in all policies” (SiAP) framework could help integrating safety into sectoral policies, such as those of transport, infrastructure, housing, leisure, entertainment, sport, justice, education, labour, social services and industry. This calls for “whole-of-government” and “whole-of-society” approaches, as well as for “system approaches”. Through these, safety could become a key component of sectoral performance, and contribute to increasing efficiency, enhancing sectoral performance, reducing inequalities and preventable loss. SiAP entails ownership and accountability for safety by relevant sectors, and promotes a shift towards a proactive identification and management of risks. It could also promote new partnerships between the safety community and different sectors, benefiting from an evidence-based public health approach to safety. Results With several of the Sustainable Development Goals (SDGs) including targets related to safety, SiAP may support the attainment of the SDGs. On the other side, the SDGs provide additional legitimacy and facilitate the implementation of SiAP by placing safety targets squarely within relevant policy domains. Conclusions SiAP requires a cultural shift, and the development of a robust understanding and appreciation of the long-term health, developmental and economic benefits offered by integrating safety in sectoral policies. It may also require changes to institutional accountability frameworks and to how sectoral performance gets appraised.

Introduction: Only one-third of the European population meets the minimum recommended levels of physical activity (PA). Physical inactivity is a major risk factor for non-communicable diseases. Walking and cycling for transport (active mobility, AM) are well suited to provide regular PA. The European research project Physical Activity through Sustainable Transport Approaches (PASTA) pursues the following aims: (1) to investigate correlates and interrelations of AM, PA, air pollution and crash risk; (2) to evaluate the effectiveness of selected interventions to promote AM; (3) to improve health impact assessment (HIA) of AM; (4) to foster the exchange between the disciplines of public health and transport planning, and between research and practice. Methods and analysis: PASTA pursues a mixed-method and multilevel approach that is consistently applied in seven case study cities. Determinants of AM and the evaluation of measures to increase AM are investigated through a large scale longitudinal survey, with overall 14 000 respondents participating in Antwerp, Barcelona, London, Örebro, Rome, Vienna and Zurich. Contextual factors are systematically gathered in each city. PASTA generates empirical findings to improve HIA for AM, for example, with estimates of crash risks, factors on AM-PA substitution and carbon emissions savings from mode shifts. Findings from PASTA will inform WHO's online Health Economic Assessment Tool on the health benefits from cycling and/or walking. The study's wide scope, the combination of qualitative and quantitative methods and health and transport methods, the innovative survey design, the general and city-specific analyses, and the transdisciplinary composition of the consortium and the wider network of partners promise highly relevant insights for research and practice. Ethics and dissemination: Ethics approval has been obtained by the local ethics committees in the countries where the work is being conducted, and sent to the European Commission before the start of the survey. The PASTA website (http://www.pastaproject.eu) is at the core of all communication and dissemination activities. This is an open access article distributed under the terms of the Creative Commons Attribution IGO License (https://creativecommons.org/licenses/by-nc/3.0/igo/), which permits use, distribution, and reproduction for non-commercial purposes in any medium, provided the original work is properly cited. In any reproduction of this article there should not be any suggestion that WHO or this article endorse any specific organisation or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.

Background:There is growing interest in “Health in All Policies” approaches, aiming at promoting health through policies which are under the control of nonhealth sectors. While economic appraisal is an established practice in transport planning, health effects are rarely taken into account. An international project was carried out to develop guidance and tools for practitioners for quantifying the health effects of cycling and walking, supporting their full appraisal.Development Process:A systematic review of existing approaches was carried out. Then, the products were developed with an international expert panel through an extensive consensus finding process.Products and Applications:Methodological guidance was developed which addresses the main challenges practitioners encounter in the quantification of health effects from cycling and walking. A “Health Economic Assessment Tool (HEAT) for cycling” was developed which is being used in several countries.Conclusions:There is a need for a more consistent approach to the quantification of health benefits from cycling and walking. This project is providing guidance and an illustrative tool for cycling for practical application. Results show that substantial savings can be expected. Such tools illustrate the importance of considering health in transport policy and infrastructure planning, putting “Health in All Policies” into practice.

Bleaches based on solutions of sodium hypochlorite (NaOCl) are widely used in the household to disinfect and clean hard surfaces and to bleach the laundry. A review of both published and unpublished toxicological data is presented. In addition, the results of a survey of human accidents with hypochlorite bleaches by the Poison Control Centers of France, Italy, Belgium, Greece, Turkey, Spain and Portugal for the period 1989-1992 are presented. The data show that acute accidental exposure to household bleach in use or in foreseeable misuse situations results, in the great majority of the cases, in minor, transient adverse effects on health, with no permanent sequelae. Ingestion is the most frequent route of exposure, followed by inhalation of gases evolved by mixing sodium hypochlorite bleach with acid or alkaline products. All evidence presented confirms the normal safety profile of hypochlorite-based bleaches to be similar to that of other 'generally recognized as safe' household products.

Background and Aims: Walking and cycling are increasingly recognized as effective forms of physical activity, an important public health priority. Urban and transport planning are more influential ...

Background and aims: Motorised traffic may discourage people walking. The main objective is to examine whether motorised transport volume influences the level of walking for transportation measured...

Increasing regular physical activity is a key public health goal. One strategy is to change the physical environment to encourage walking and cycling, requiring partnerships with the transport and urban planning sectors. Economic evaluation is an important factor in the decision to fund any new transport scheme, but techniques for assessing the economic value of the health benefits of cycling and walking have tended to be less sophisticated than the approaches used for assessing other benefits. This study aimed to produce a practical tool for estimating the economic impact of reduced mortality due to increased cycling. The tool was intended to be transparent, easy to use, reliable, and based on conservative assumptions and default values, which can be used in the absence of local data. It addressed the question: For a given volume of cycling within a defined population, what is the economic value of the health benefits? The authors used published estimates of relative risk of all-cause mortality among regular cyclists and applied these to levels of cycling defined by the user to produce an estimate of the number of deaths potentially averted because of regular cycling. The tool then calculates the economic value of the deaths averted using the "value of a statistical life." The outputs of the tool support decision making on cycle infrastructure or policies, or can be used as part of an integrated economic appraisal. The tool's unique contribution is that it takes a public health approach to a transport problem, addresses it in epidemiologic terms, and places the results back into the transport context. Examples of its use include its adoption by the English and Swedish departments of transport as the recommended methodologic approach for estimating the health impact of walking and cycling.

Objective: To examine the impact of traffic on levels of walking and bicycling. Method: Review of the literature of medical, public health, city planning, public administration and traffic engineering. Results: The real and perceived danger and discomfort imposed by traffic discourage walking and bicycling. Accurately or not, pedestrians and bicyclists judge injury risk and respond accordingly. Although it can be difficult to measure these effects, observed behaviour provides good evidence for these effects, with the strongest association being an inverse correlation between volumes and speeds of traffic and levels of walking and cycling. Conclusion: Interventions to reduce traffic speed and volume are likely to promote walking and bicycling and thus result in public health gains.

We reviewed published and unpublished studies that presented the findings of an economic valuation of an aspect of transport infrastructure or policy, and included data on walking and/or cycling and health effects in the valuation. We included 16 papers, of which three were classified as ‘high; six as ‘moderate’ and seven as ‘low’ quality. There is a wide variation in the approaches taken for including the health effects of physical activity in economic analyses of transport projects. This is not helped by a lack of transparency of methods in many studies. A more standardised approach is called for, including a clearer description of the applied methods and assumptions taken.

From the mid-1990s, research began to highlight the importance of a wide range of health impacts of transport policy decisions. The Third Ministerial Conference on Environment and Health adopted a Charter on Transport, Environment and Health based on four main components: bringing awareness of the nature, magnitude and costs of the health impacts of transport into intergovernmental processes; strengthening the arguments for integration of health into transport policies by developing in-depth analysis of the evidence; developing national case studies; and engaging ministries of environment, health and transport as well as intergovernmental and nongovernmental organizations. Negotiation of the Charter was based on two converging processes: the political process involved the interaction of stakeholders in transport, health and environment in Europe, which helped to frame the issues and the approaches to respond to them; the scientific process involved an international group of experts who produced state-of- the-art reviews of the health impacts resulting from transportation activities, identifying gaps in existing knowledge and methodological tools, specifying the policy implications of their findings, and suggesting possible targets for health improvements. Health arguments were used to strengthen environmental ones, clarify costs and benefits, and raise issues of health equity. The European experience shows that HIA can fulfil the need for simple procedures to be systematically applied to decisions regarding transport strategies at national, regional and local levels. Gaps were identified concerning models for quantifying health impacts and capacity building on how to use such tools.

This study shows how the World Health Organization (WHO) undertook a global survey to assess the road safety situation in all Member States in 2008. The objective of this study is to assess the status of road safety in the WHO European Region and also to provide a baseline assessment of how far countries have come in implementing the recommendations of the World report on road traffic injury prevention. The survey used a standardized questionnaire administered to multisectoral respondents. It shows how 49 out of 53 States belonging to the WHO European Region took part in the survey, which represents 99% of the population. In the Region, road crashes result in 120,000 deaths annually, 2.4 million injuries and a great economic burden. Vulnerable road users such as pedestrians, cyclists and users of motorized two-wheelers constitute 50,000 (or 39%) of all road traffic injury fatalities, with pedestrians being twice at risk in the eastern part of the Region compared to the western. Countries differ greatly in mortalities for road traffic injuries; the average in low- and middle-income countries is twice that in high-income countries. Despite the dramatic achievements in some countries, safety on the roads still remains critical in certain areas of the region. The following actions are proposed: narrow the gap between countries with the lowest and highest mortalities; provide better protection for vulnerable road users; develop a well-resourced multisectoral road safety strategy in each country; design and enforce comprehensive legislation; and develop and implement healthier transport policies.

Introduction Injuries and violence are the third leading cause of death in WHO European Region and pose a threat to economic and social development. Aim and methods The results of a 3-year collaborative project between WHO and the European Commission on progress achieved by Member States in implementing resolution EUR/RC55/R9 and the European Council Recommendation on the prevention of injuries are presented. A web-based database of country profiles was developed using a questionnaire survey completed by health ministry focal persons for injury and violence prevention. Information was provided on progress in delivering on key items of resolution EUR/RC55/R9 and on the implementation of 99 selected evidence-based programmes to prevent unintentional injury and violence and on the cross-cutting risk factors of alcohol and socioeconomic inequalities. Results There were responses from 47 of the 51 Member States with focal persons. Good progress is taking place, and resolution EUR/RC55/R9 has catalysed change in 75% of respondent countries. Development of national policies for individual types of injury and violence varied from 95% for road safety to 40% for preventing drowning. Implementation of evidence-based programmes for preventing all types of injury and violence varied in countries, and the median score was 73% for all these together. Conclusions This project reports that the health sector needs to commit more to the widespread implementation of effective programmes both in number and coverage, and to engage with other stakeholders in a multisectoral response to prevent injuries and violence.

On 10–12 March 2010, ministers of environment and health of the 53 countries in the WHO European Region (and a number of international governmental and non-governmental organizations) will meet in Parma, Italy, on the occasion of the Fifth Ministerial Conference on Environment and Health. One major item in their agenda is going to be the increasing challenge of inequities in exposure to environmental hazards. These inequities emerge both between and within countries, and are significantly influenced by social conditions.1 The recent economic crisis has further exposed the potential exacerbating effect that social factors may have on inequities and their consequences for health.2 To support its Member States in developing more informed policies on the environmental dimension of health inequities, WHO commissioned evidence reviews on the occurrence and extent of social inequities in exposure to selected environmental risk factors with a specific focus on inequities affecting children.3 Social factors considered in these reviews were socioeconomic status (income, education, employment), age, gender, ethnicity, or being part of a minority group. Summaries of the reviews on social inequities in housing4, waste management5, air pollution6 and children's environment7 are published in this issue of the EJPH. The compiled evidence was reviewed by 40 experts from 20 countries at a consultation meeting convened by WHO in Bonn on 9–10 September, 2009, resulting in a set of policy recommendations on possible measures to be undertaken to alleviate the inequities and their health burden. …

Road traffic injuries are a leading cause of death worldwide, accounting for 1.2 million deaths annually. In 2002, road traffic accidents were responsible for 127 000 deaths in the WHO European Region.1 Recently, there have been calls for global action to reduce this public health threat, and the First United Nations Global Road Safety Week was held on 23–29 April 2007.2 Activities during the week focused specifically on preventing road traffic injuries in young people under the age of 25 years. The WHO European Region faces substantial challenges in this respect, as each year 32 000 young people aged under 25 are killed in road traffic accidents in Europe.3 Road traffic injuries are the leading cause of death in the 5–24 years age group.3 However, deaths are only the tip of the iceberg, and it is estimated that, for every death, 20 people are hospitalised and another 70 require outpatient medical treatment.4 5 Although data on non-fatal outcomes and costs are incomplete, the available evidence suggests that the health care and societal costs are enormous, with the latter estimated at 2% of gross domestic product for most countries in the region.1 6 The nature of the risk and exposure changes with age: among European children under 15 years, pedestrians account for the majority of fatalities, whereas in the 15–24 years age group most road death victims are car occupants (59%) or motorcyclists (19%).3 Programmes aimed at reducing road traffic deaths should take into consideration the different needs of groups at different stages of development from infancy to …