[Sustainable Urban Health as a conceptual and action approach]. / Nachhaltige StadtGesundheit als Denk- und Handlungsansatz.

The field of urban health, i.e., the application of public health for people in the city, is oriented towards both scientific knowledge and practical action. In the international arena, a scientific infrastructure exists for this purpose. Despite the common roots of public health and urban planning in Germany, the connection between these fields of work was not very apparent for a long time. Legal requirements for the participation of public health service in (urban) planning processes have had little impact so far. The aim of this study was to connect to international urban health developments in order to make the topic more visible, to support professional exchange and to give impulses for research and practice. To express the close links between human health, ecological stability and social justice, the approach was conceived as sustainable urban health. With this in mind, the program "City of the Future - Healthy, Sustainable Metropolises" was initiated in 2011.This article characterizes the basic approach as integrating and describes the underlying guiding principles, i.e., "View field expansion" as an epistemological principle and "Bridge building" as an action-guiding principle, and outlines the details. The spectrum of topics ranges from medical and nursing care over "classical" prevention and health promotion to health in all policies. Within this approach, "smaller" tasks can be pursued, e.g., an overview of local health actions and actors, networking promotion, or preserving significant developments in collective memory. At the same time, it is about contributions to the solution of "big" tasks, e.g., the derivation of conclusions from the Corona learning experience, a more consistent implementation of health in all policies, or transformation steps towards an ecologically sustainable development of society. Legal norms, public health services, health reporting, and urban planning come up as leitmotifs. The article also outlines the genesis of the position papers in this supplementary volume and concludes with an outlook.

[Urban Epidemiology as an Integrative Approach to Sustainable and Healthy Urban Development]. / Stadtepidemiologie als integrativer Ansatz für eine nachhaltige, gesundheitsfördernde Stadtentwicklung.

Understanding the complex relationships between the physical and social environment and health in urban areas is essential for the development of appropriate measures of health promotion, disease prevention, and health protection. This article aims to characterize the comparatively new approach of urban epidemiology with its relevance for research and practice of urban health. Research in urban epidemiology provides important data and methodological foundations for integrated reporting, health impact assessments, and evaluation of interventions. Current challenges and solutions are outlined and initial recommendations for research, practice, and education and training are presented for discussion. Methods and findings of urban epidemiology can contribute in many ways to health-promoting, sustainable urban development.

[City Planning, Urban Initiatives and Health]. / Stadtplanung, urbane Initiativen und Gesundheit.

Urban planning and public health are main fields of action when looking at urban development from a health perspective. In both fields of action, politics and administration as well as urban initiatives play a formative role. Action is oriented towards common overarching themes of sustainability, social justice and environmental justice. These commonalities are reflected in different memoranda. Despite the common basis of urban planning and health, there are areas of tension that are rooted, among other things, in different legal frameworks and logic of action. Against this complex background, recommendations are formulated for science, the funding landscape, practice as well as education and training in these areas.

[Mobility and Urban Health]. / Mobilität und StadtGesundheit.

Cities and communities form complex microcosms in which people with very different needs and opportunities live. The structural design and functionality of urban spaces have a significant impact on individual mobility and thus on the health and quality of life of the entire population. In recent decades, politicians and municipalities have accepted negative effects on people (especially vulnerable groups) and ecosystems as a price worth paying for ensuring mobility through car-friendly structures. The interconnection of health and sustainability aspects will be a central process component for the necessary transformation of urban structures in integrated urban and transport planning. Although there are many positive framework conditions and possible solutions in the international and national context, numerous processes need to be optimized and measures implemented on a large scale. In addition, the existing tools in urban and traffic planning must be further expanded to include health aspects more comprehensively. This requires readjustments in science, in municipal practice planning, in education and in interdisciplinary funding programs.

[Research program "City of the Future - Healthy and Sustainable Metropolises"]. / Forschungsförderprogramm "Stadt der Zukunft ­ gesunde und nachhaltige Metropolen".

Urbanization is advancing worldwide and thus, cities are increasingly living spaces for people. Therefore, it is essential to place the health and well-being of city dwellers at the center of urban planning. The research funding program "City of the Future - Healthy and Sustainable Metropolises" from the Fritz and Hildegard Berg Foundation at the German Stiftungszentrum has been providing important inter- and transdisciplinary research impulses on this topic since 2010. Junior research groups at the interfaces of health sciences and other disciplines in the natural and social sciences were funded. One focus of the research program is to enable intensive cooperation with practitioners, in order to reflect upon and work on problems and issues from practice using the best possible scientific methods and to catalyze the transfer of knowledge. The research consortia are accompanied by annual conferences on a wide variety of urban health topics at various venues in Germany. In addition, transdisciplinary networks have been established and further initiatives (e. g., founding of an institute) have been launched. In this paper, the development of the multifaceted research funding program "City of the Future - Healthy and Sustainable Metropolises" is presented, including an outlook into its future development.

[Urban green and blue spaces in times of climate change]. / Stadtgrün und Stadtblau im Klimawandel.

Both climate mitigation and adaptation are urgently needed as complementary strategies for sustainably reducing and managing urban health risks posed by climate change. The positive effects of urban green and blue spaces on physical and mental health are well-known since decades. However, there is intensive competition around the use of the urban space. Reflecting the European Aalborg Charta (1994), German building laws require development plans to be sustainable in this demanding context with human health being a concern of central importance. Reality, however, remains challenging. Although there are numerous best practice examples, research on the impact of urban green and blue spaces on human health and well-being is still required. Furthermore, all relevant policy fields need to develop awareness of the importance of green and blue spaces for quality of life and health, so that the issue of health is taken into consideration adequately as well as in a socially sensitive manner in urban decision processes.

[Sustainable urban health: conceptual foundations and current initiatives]. / Nachhaltige StadtGesundheit: konzeptionelle Grundlagen und aktuelle Initiativen.

The interactions between cities/settlements and health have been an issue of discussion since antiquity. Since the late 1970s, there has been renewed interest in the role of nonmedical determinants of health. This paper aims to retrace the development of relevant new concepts during the last 40 years, clarify their mutual relationships, and from this background present the concept of sustainable urban health. For this purpose, a secondary analysis is conducted and relevant documents and literature are being interpreted.After an introduction using illustrative examples of urban health, the paper describes how the WHO has provided crucial input to a renewed debate on public health since the 1970s, based on concepts such as "multi-/intersectoral action," "healthy public policy," and "health in all policies." Sustainable urban health, tying in with this tradition, is characterized as a program of expanding the horizon and of building bridges between disciplines and societal sectors. This is exemplified by a local initiative in the city of Hamburg.Rather than being substantially different, the WHO concepts may be seen as representing various shades of emphasis. Health in all policies (HiAPs) are in line with the UN Declaration of Human Rights and the UN Sustainable Development Goals; the concept succeeded in being integrated into both WHO and EU policy making. Additional work is required for the sustainable urban health goal to synchronously promote health and sustainability in urban societies.

Health assessments for health governance-concepts and methodologies.

Background: For better supporting the science-governance interface, the potential of health assessments appears underrated. Aims: To identify what various types of health assessment have in common; how they differ; which assessment(s) to apply for which purpose; and what needs and options there are for future joint development. Methods: This review is based on five types of health assessment: monitoring/surveillance/reporting, assessment of health impact, of health technology, of health systems performance, health-related economic assessment. The approach is exploratory and includes: applying an agreed set of comparative criteria; circulating and supplementing synoptic tables; and interpreting the results. Results: Two of the assessments deal with the question 'Where do we stand?', two others with variants of 'What if' questions. Economic Assessment can take place in combination with any of the others. The assessments involve both overall 'procedures' and a variety of 'methods' which inescapably reflect some subjective assumptions and decisions, e.g. on issue framing. Resources and assistance exist for all these assessments. The paper indicates which type of assessment is appropriate for what purpose. Conclusions: Although scientific soundness of health assessments is not trivial to secure, existing types of health assessment can be interpreted as a useful 'toolkit' for supporting governance. If current traces of 'silo' thinking can be overcome, the attainability of a more unified culture of health assessments increases and such assessments might more widely be recognized as a prime, 'tried and tested' way to voice Public Health knowledge and to support rational governance and policy-making.

A nonparametric random coefficient approach for life expectancy growth using a hierarchical mixture likelihood model with application to regional data from North Rhine-Westphalia (Germany).

BACKGROUND: Life expectancy is of increasing prime interest for a variety of reasons. In many countries, life expectancy is growing linearly, without any indication of reaching a limit. The state of North Rhine-Westphalia (NRW) in Germany with its 54 districts is considered here where the above mentioned growth in life expectancy is occurring as well. However, there is also empirical evidence that life expectancy is not growing linearly at the same level for different regions. METHODS: To explore this situation further a likelihood-based cluster analysis is suggested and performed. The modelling uses a nonparametric mixture approach for the latent random effect. Maximum likelihood estimates are determined by means of the EM algorithm and the number of components in the mixture model are found on the basis of the Bayesian Information Criterion. Regions are classified into the mixture components (clusters) using the maximum posterior allocation rule. RESULTS: For the data analyzed here, 7 components are found with a spatial concentration of lower life expectancy levels in a centre of NRW, formerly an enormous conglomerate of heavy industry, still the most densely populated area with Gelsenkirchen having the lowest level of life expectancy growth for both genders. The paper offers some explanations for this fact including demographic and socio-economic sources. CONCLUSIONS: This case study shows that life expectancy growth is widely linear, but it might occur on different levels.

Health status of 'Ruhr-City' in 2025--predicted disease burden for the metropolitan Ruhr area in North Rhine-Westphalia.

BACKGROUND: Demographic change is a driving force of disease burden. The German population is aging and simultaneously shrinking, due to a rising life expectancy and a declining fertility rate. North Rhine-Westphalia (NRW) is the most populous federal state of Germany including the Ruhr metropolitan area. The NRW population is expected to shrink by 2.5% until 2025, the population of the Ruhr area by 9.5%. At the same time, the population forecast predicts a growth of 30% in the age group > or =55 years for NRW. METHODS: The 'burden of disease' approach of the World Health Organisation (WHO) summarizes the health status of populations. This approach was used to predict the regional disease burden in 2025 by calculating disability adjusted life years (DALY) as the sum of life years lost due to premature death and years lived with disability due to selected diseases. Our projection included selected tumours, myocardial infarction (MI) and dementia. RESULTS: For the Ruhr area, increases in DALYs are expected for all causes studied, i.e. selected tumours (20%), MI (17%) and dementia (36%). The increase in the Ruhr area was estimated to be proportionally lower than in NRW in total, but the disease burden per inhabitant is higher. CONCLUSION: The population shrinking is no cure for 'Ruhr City'. The projection of disease burden shows that health status will decrease due to the demographic change. DALY estimates show the potential health gains, which can be won by implementing measures to reduce premature deaths and to prevent new cases.

Quantitative health impact assessment: taking stock and moving forward.

Over the past years, application of health impact assessment has increased substantially, and there has been a strong growth of tools that allow quantification of health impacts for a range of health relevant policies. We review these developments, and conclude that further tool development is no longer a main priority, although several aspects need to be further developed, such as methods to assess impacts on health inequalities and to assess uncertainties. The main new challenges are, first, to conduct a comparative evaluation of different tools, and, second, to ensure the maintenance and continued availability of the toolkits including their data contents.

Towards health impact assessment of drinking-water privatization--the example of waterborne carcinogens in North Rhine-Westphalia (Germany).

Worldwide there is a tendency towards deregulation in many policy sectors - this, for example, includes liberalization and privatization of drinking-water management. However, concerns about the negative impacts this might have on human health call for prospective health impact assessment (HIA) on the management of drinking-water. On the basis of an established generic 10-step HIA procedure and on risk assessment methodology, this paper aims to produce quantitative estimates concerning health effects from increased exposure to carcinogens in drinking-water. Using data from North Rhine-Westphalia in Germany, probabilistic estimates of excess lifetime cancer risk, as well as estimates of additional cases of cancer from increased carcinogen exposure levels are presented. The results show how exposure to contaminants that are strictly within current limits could increase cancer risks and case-loads substantially. On the basis of the current analysis, we suggest that with uniform increases in pollutant levels, a single chemical (arsenic) is responsible for a large fraction of expected additional risk. The study also illustrates the uncertainty involved in predicting the health impacts of changes in water quality. Future analysis should include additional carcinogens, non-cancer risks including those due to microbial contamination, and the impacts of system failures and of illegal action, which may be increasingly likely to occur under changed management arrangements. If, in spite of concerns, water is privatized, it is particularly important to provide adequate surveillance of water quality.

Health in impact assessments: opportunities not to be missed

Prospective impact assessment is a consolidated approach for pursuing foresight in policy and decision-making, systematically deployed worldwide. There is consensus that, even in well developed impact assessments, human health is not always covered adequately. Partly as a response, health impact assessment (HIA) has emerged and has been applied in several countries in Europe and beyond. Opinions about the merits of HIA separate from other forms of impact assessment differ. This publication aims to provide a detailed and balanced view on “health in impact assessments”. Five key types of impact assessment, namely environmental impact assessment, strategic environmental assessment, social impact assessment, sustainability assessment, and HIA are presented, and four key questions are discussed: How can the various assessments contribute to promoting and protecting human health? How can further integration of health support the various forms of impact assessments? What forms of integration seem advisable? What priorities for further development? This analysis suggests that the potential of impact assessments to protect and promote health is underutilized, and represents a missed opportunity. Ways need to be found to exploit the potential to a fuller extent.