Participatory quantitative health impact assessment of urban and transport planning in cities: A review and research needs.

TL;DR: An overview of the current state of the art of HIA in cities is provided, the need for novel participatory quantitative health impact assessments (HIA) is described, and recommendations for further work are provided.

Abstract: Introduction Urban and transport planning have large impacts on public health, but these are generally not explicitly considered and/or quantified, partly because there are no comprehensive models, methods and tools readily available. Air pollution, noise, temperature, green space, motor vehicle crashes and physical activity are important pathways linking urban and transport planning and public health. For policy decision-making, it is important to understand and be able to quantify the full-chain from source through pathways to health effects and impacts to substantiate and effectively target actions. In this paper, we aim to provide an overview of recent studies on the health impacts related to urban and transport planning in cities, describe the need for novel participatory quantitative health impact assessments (HIA) and provide recommendations. Method To devise our searches and narrative, we were guided by a recent conceptual framework linking urban and transport planning, environmental exposures, behaviour and health. We searched PubMed, Web of Science, Science Direct, and references from relevant articles in English language from January 1, 1980, to November 1, 2016, using pre-defined search terms. Results The number of HIA studies is increasing rapidly, but there is lack of participatory integrated and full-chain HIA models, methods and tools. These should be based on the use of a systemic multidisciplinary/multisectorial approach and state-of-the-art methods to address questions such as what are the best, most feasible and needed urban and transport planning policy measures to improve public health in cities? Active citizen support and new forms of communication between experts and citizens and the involvement of all major stakeholders are crucial to find and successfully implement health promoting policy measures. Conclusion We provided an overview of the current state-of-the art of HIA in cities and made recommendations for further work. The process on how to get there is as important and will provide answers to many crucial questions on e.g. how different disciplines can effectively work together, how to incorporate citizen and stakeholder opinion into quantitative HIA modelling for urban and transport planning, how different modelling and measurement methods can be effectively integrated, and whether a public health approach can bring about positive changes in urban and transport planning.

Summary

Introduction

• Within and between cities, there is considerable variation in the levels of important environmental exposures such as air pollution, noise, temperature and green space, and in physical activity and motor vehicle crashes, partly due to urban and transport planning practices (Nieuwenhuijsen 2016).
• Furthermore, they also need to build an effective dialogue with the population that produces environmental stressors and is impacted at the same time, ensuring in this way public awareness and acceptance, as some measures can be restrictive in nature and therefore be politically unpopular (e.g. vehicle restricted areas and congestion charging zones).
• Health Impact Assessment (HIA) has been proposed as one of the main tools to integrate evidence in the decision-making process, and introduce health in all policies (WHO, 1999; Stahl et al, 2006; NAS, 2011).

Methods

• To devise their searches and narrative, the authors were guided by a conceptual framework linking urban and transport planning, environmental exposures, behaviour and health .
• Transport mode choice is associated with a range of environmental exposures such as air pollution and noise, which in turn are associated with morbidity and mortality.
• Finally, green space provision may lead to e.g. improved mental health and more physical activity and social contacts and therefore reduce morbidity and mortality.
• The authors do not systematically report the results, but focus on studies, systematic reviews, and meta-analyses published in the past five years (i.e. 2012 to 2016); to provide the latest and most up to date information.
• The authors furthermore searched Google for any other material related to “health impact assessment” and “urban and transport planning”.

Quantitative Health Impact Assessment

• The most common HIAs are qualitative, aiming only to identify the range of the health determinants associated with a policy, intervention or scenario, and the direction of its impacts (risk or benefit).
• This, in part, is perhaps a reflection of a communication gap between the sectors where non-academic stakeholders lack the tools, knowledge and interest to carry out a quantitative HIA whilst academics/researchers lack the expertise and understandings as to what extent scenarios are plausible, realizable and acceptable to local authorities or policy makers.
• A recent study for Warsaw estimated more than 40,000 DALYs attributable to air pollution, noise and traffic injuries, with traffic noise contributing the largest (Tainio, 2015).
• Woodcock et al (2009) estimated the health effects of alternative urban land transport scenarios for two settings-London, UK, and Delhi, India and found that a combination of active travel and lower-emission motor vehicles would give the largest benefits (7439 DALYs in London, 12 995 in Delhi).
• Some of the main problems conducting quantitative HIAs on a city level are the lack of availability of baseline data for some of the exposures and health outcomes, the implied need to make assumptions of these parameters and how to deal with uncertainty.

Full-Chain Exposure Assessment

• Exposure assessment, which provides input into HIA is often considered as the weakest part in the HIA chain, particularly if it does not fully incorporate the full characteristics of the exposure, including its sources, pathways and variations.
• Traffic indicators such as distance to roads, surrounding road length, traffic density, and urban indicators such as household density, industry and natural outdoor environments including green space explain a large proportion of the variability of air pollution levels within urban areas (Eeftens et al 2012a, Beelen et al 2013).
• They depend e.g. on human activity, population density, green vegetation, urban design and albedo effects (Zhang et al 2013, Gago et al 2013, Petralli et al 2014).
• In the case of air pollution exposures, the common lack of full-chain assessment limits disentangling the health impacts of traffic-related air pollution (TRAP) from the health impacts of other emission sources, and vice versa (Khreis et al. 2016 b).
• Often, such assessments can be problematic as the referred to models are data and labor intensive and require expertise from different scientific disciplines.

Citizen and Other Stakeholder Involvement.

• Changes in city urban and transport planning are difficult to achieve and sustain without direct support of politicians, decision makers, and citizens.
• Secondly, participation allows to increase public acceptability of decisions and to build stronger consensus, reduce conflicts and produce shared projects and visions (van de Kerkhof, 2006; Innes & Booher, 2004).
• These other forms of knowledge can support the evidence built with quantitative measurements with nuanced qualitative inputs and local knowledge on political and social circumstances (Linzalone et al. 2016) and to formulating more sustainable recommendations contributing to raised awareness of health impacts, increasing effectiveness and applicability of the outcomes.
• The literature reports only a few studies in which stakeholders have been consulted during HIA (e.g. Kearney 2004, Greig et al.
• In HIA, citizens and stakeholder participation should occur in the selection of the scenarios, identification of health effects and vulnerable populations, selection and periodization of recommendations; identifying the best channels of dissemination and monitoring and evaluation (Table 1).

In summary

• They also need to build this in dialogue with the public and other stakeholders, creating an environment of collaboration and feedback and guaranteeing public acceptance of proposed policy measures.
• The lack of public awareness has been previously suggested to reinforce the lack of political commitment and initiative to address these problems (Khreis et al. 2016 a).
• A full-chain approach also allows decision makers to target their actions at different stages in the chain so they can make cost effective decisions at each stage.

Quantitative and qualitative approaches

• Currently there is no overarching HIA model for cities that can deal with multiple exposures and complexities, data limitations, location-specific effects, errors etc., and the authors must work with separate quantitative and qualitative models/modules which from one perspective may be considered as an advantage to reduce the complexity and burden of this work.
• Quantitative HIAs are unlikely to be conducted for small projects, where generally little funding is available, although if models are previously set-up and exposures are readily available for the area, then undertaking the assessment would be feasible.
• They also would object to large changes when they have not been involved in decision making (e.g. Barcelona SuperIlles).
• A participatory, quantitative HIA ensures that no aspect is forgotten, that the process is inclusive and comprehensive and that a consensus can be reached at the end by weighing the estimated risks against the benefits.
• The way these studies have been performed also shows how multidisciplinary teams of academics, both from qualitative and quantitative backgrounds, would can take the process through all its phases.

Challenges

• One challenge for HIA is getting good input data for e.g. exposure, exposure-response relationships and health outcomes, and this type of high quality data may not be always available.
• The participation of different stakeholders, approached with a variety of methods and participatory tools, is crucial for the identification of specific and high quality data.
• Quantitative HIA can highlight these limitations and also be combined with qualitative HIA, so to generate recommendations able to involve and inform the stakeholders in a broader dimension.
• A further challenge is now to make models accessible, so that they can be used outside the research community by practitioners and policy makers.
• Simplification without losing the essence may be the answer and this is for example the approach in the PASTA project.

Further research needs

• So far scenarios have tended to be fairly simplistic, partly to enable the modelling but the reality is more complex and there are limitations to what can be achieved.
• Many of the current models focus only on a few exposures e.g. air pollution, physical activity or road safety (Mueller et al 2015), or start with a given exposure level (Mueller et al 2016) without trying to identify the sources and pathways (i.e. full-chain).
• There is a large and still growing evidence base that needs to be reviewed, synthesized and implemented in a model/tool that can be used extensively by relevant stakeholders.
• Better governance is needed to introduce health in all polices, and multisectoral approaches and the integration of multiple levels of government (local, regional and national) to effectively implement the evidence in the decision making process.

Uncertainty

• Uncertainty may occur when conceptualising the problem, during analysis and/or while communicating the results (Briggs et al 2009).
• Therefore, more participatory approaches to investigation, and more qualitative measures of uncertainty, are needed, not only to define uncertainty more inclusively and completely, but also to help those involved better understand the nature of the uncertainties and their practical implications (Briggs et al 2009).
• These results were the basis for transport policy making in the area including for example buses replacement with low emission ones (https://www.bradford.gov.uk/media/1384/reportofthelezfeasibilitystudy.pdf ).
• Often, there is a disconnect between researchers who understand the value of the quantitative HIA process and practitioners who feel they lack the time and/or expertise to conduct a quantitative HIA, and rely more on qualitative approaches.
• HIA professionals should also be trained and able to work in multidisciplinary teams.

Low and medium income countries

• Finally, most of the work so far has been done in high income countries.
• There is a need for this type of work outside high income countries, where urbanization rates are the highest, where there is the greatest burden of disease related to noncommunicable diseases and where many cities are in the process of being shaped leaving room for timely interventions.
• Yet, at the same time low and medium income regions and countries have a real opportunity ahead, to improve and consider public health in the urban and transport development, avoiding the mistakes made by developed countries.

Conclusions

• There is a need to improve healthy life through healthy urban and transport planning.
• Identification of relevant health effects and populations affected including stakeholders and citizen perspectives.
• Introduce integrated, full-chain and complex system approach.
• Introduce the stakeholder and citizen perspective in the evaluation of the process, based on an iterative process to strength the citizens and stakeholder capacities.
• G) Develop citizen science approaches in public health.

Figures

Table 2. General description of examples of Urban and Transport Policies/Interventions/Scenarios that could be modeled using Health impact assessment

Figure 3 Participatory full-chain health impact assessment with an example for air quality

Figure 1 Conceptual framework of links between urban and transport planning, environmental exposures, physical activity and health (after Nieuwenhuijsen 2016)

Figure 2. Connection between parts of the work in a Health Impact Assessment framework

Table 3. Recommendations for politicians/authorities, urban and transport experts, public health practitioners and researchers.

Frequently asked questions

Q1. What have the authors contributed in "Participatory quantitative health impact assessment of urban and transport planning in cities: a review and research needs" ?

Nieuwenhuijsen et al. this paper showed that 20 % of premature mortality in a city like Barcelona is related to urban and transport planning related exposures, including air pollution, noise, temperature, green space, and physical activity, not meeting international exposure level guidelines. 

Q2. What are the future works mentioned in the paper "Participatory quantitative health impact assessment of urban and transport planning in cities: a review and research needs" ?

An important component of further research is the improvement or further development of conceptual frameworks for urban and transport planning, environmental exposures, behaviour and health bringing in aspects of the full-chain of events and considering multiple exposures and complexities, interdependencies and uncertainties of the real world ( Briggs 2008, de Nazelle et al 2011, MacMillan et al 2014, Nieuwenhuijsen 2016, Giles Corti et al 2016, Verbeek and Boelens 2016 ). A further research need is how to have citizens participate in the process and get to grips with the complexities that may occur especially when aiming to develop quantitative models. Further work is also needed on the assessment of governance structure in cities and to obtain political input on urban and transport planning effects on population health, acceptability, facilitators and impediments to any recommended interventions. These frameworks may go well beyond what actually can be quantitatively modelled, at the time being, but at least allow for assessment of model uncertainty and potential bias recognizing aspects that have not previously been taken into account.