Protective effect of restorative possibilities on cognitive function and mental health in children and adolescents: A scoping review including the role of physical activity.

Background The exposome approach can be a powerful tool for understanding the intertwining of social, physical, and internal influences that shape mental health and cognitive development throughout childhood. To distil conceptual models for subsequent analyses, the EU-funded project Early Environmental quality and Life-course mental health effects (Equal-Life) has conducted literature reviews on potential mediators linking the exposome to these outcomes. We report on a scoping review and a conceptual model of the role of restorative possibilities and physical activity. Methods Peer-reviewed studies published since the year 2000 in English, on the association between the exposome and mental health/cognition in children/adolescents, and quantitatively investigating restoration/restorative quality as a mediating variable were considered. Database searches were last updated in December 2022. We used an unstructured expert-driven approach to fill in gaps in the reviewed literature. Results Five records of three distinct studies were identified, indicating a scarcity of empirical evidence in this newly developing research area. Not only were these studies few in numbers, but also cross-sectional, lending only tentative support to the idea that perceived restorative quality of adolescent's living environment might mediate the association between greenspace and mental health. Physical activity emerged as a mediator leading to better psychological outcomes in restorative environments. We provide a critical discussion of potential caveats when investigating the restoration mechanism in children and propose a hierarchical model including restoration, physical activity, and relational dynamics between children and their environment, including social context, as well as restorative environments other than nature. Conclusions It is justified to further explore the role of restoration and physical activity as mediators in the association between early-life exposome and mental health/cognitive development. It is important to consider the child perspective and specific methodological caveats. Given the evolving conceptual definitions/operationalizations, Equal-Life will attempt to fill in a critical gap in the literature.

Adopting a child perspective for exposome research on mental health and cognitive development - Conceptualisation and opportunities.

Mental disorders among children and adolescents pose a significant global challenge. The exposome framework covering the totality of internal, social and physical exposures over a lifetime provides opportunities to better understand the causes of and processes related to mental health, and cognitive functioning. The paper presents a conceptual framework on exposome, mental health, and cognitive development in children and adolescents, with potential mediating pathways, providing a possibility for interventions along the life course. The paper underscores the significance of adopting a child perspective to the exposome, acknowledging children's specific vulnerability, including differential exposures, susceptibility of effects and capacity to respond; their susceptibility during development and growth, highlighting neurodevelopmental processes from conception to young adulthood that are highly sensitive to external exposures. Further, critical periods when exposures may have significant effects on a child's development and future health are addressed. The paper stresses that children's behaviour, physiology, activity pattern and place for activities make them differently vulnerable to environmental pollutants, and calls for child-specific assessment methods, currently lacking within today's health frameworks. The importance of understanding the interplay between structure and agency is emphasized, where agency is guided by social structures and practices and vice-versa. An intersectional approach that acknowledges the interplay of social and physical exposures as well as a global and rural perspective on exposome is further pointed out. To advance the exposome field, interdisciplinary efforts that involve multiple scientific disciplines are crucial. By adopting a child perspective and incorporating an exposome approach, we can gain a comprehensive understanding of how exposures impact children's mental health and cognitive development leading to better outcomes.

[Reduction in the noise pollution within residential environments - what has been achieved so far?] / Verringerung der Lärmbelastungen am Wohnort ­ Was wurde bisher erreicht?

Surveys show that noise in its various forms is among the most severe environmental burdens. According to estimates of the World Health Organization (WHO), there is a loss of one million healthy life years per year in Europe due to the effects of environmental noise. This paper discusses the harmful effects of noise with the example of traffic noise, for which the highest number of environmental noise effect studies are available. An increasing number of studies show associations between traffic noise and vascular, metabolic and psychic diseases. Too little is still known about the causal mechanisms, even though a number of explanatory models are available. However, it is clear that today it is no longer a question of whether noise is responsible for extra-aural diseases, but under what conditions and to what extent are the risks.The high degree of noise nuisance shows that more action is needed with regard to noise control policy.Over the past few years, federal, regional and local governments have taken countless initiatives on traffic noise control - for instance, within the framework of action plans. Especially notable are the innovative measures, instruments and programs regarding railway noise. In the most important source of nuisance, road traffic noise, less progress has been made. In air traffic noise, too, the revision and development of important laws are still lacking. To promote inner urban development, the level of protection against industrial and sports noise has been reduced.Significant health-related reductions in noise pollution (except regarding the railways), therefore, cannot be expected in the near future.

Exposure to Online Alcohol Marketing and Adolescents' Drinking: A Cross-sectional Study in Four European Countries.

AIMS: The Internet is the leading medium among European adolescents in contemporary times; even more time is spent on the Internet than watching television. This study investigates associations between online alcohol marketing exposure and onset of drinking and binge drinking among adolescents in four European countries. METHOD: A total of 9038 students with a mean age of 14.05 (SD 0.82) participated in a school-based survey in Germany, Italy, the Netherlands and Poland. Logistic regression analyses of cross-sectional cross-country survey data were undertaken. Exposure to online alcohol marketing, televised alcohol advertising and ownership of alcohol-branded items was estimated to be controlled for relevant confounders. Onset of drinking and binge drinking in the past 30 days were included in the study as outcome variables. RESULTS: Adjusted for relevant confounders, higher exposure to (online) alcohol marketing exposure was found to be related to the odds of starting to drink (p < 0.001) and the odds of binge drinking in the past 30 days (p < 0.001). This effect was found to be consistent in all four countries. Active engagement with online alcohol marketing was found to interact more strongly with drinking outcomes than passive exposure to online alcohol marketing. CONCLUSIONS: Youngsters in the four European countries report frequent exposure to online alcohol marketing. The association between this exposure and adolescents' drinking was robust and seems consistent across national contexts.

Being a Fair Neighbor-Towards a Psychometric Inventory to Assess Fairness-Related Perceptions of Airports by Residents-Development and Validation of the Aircraft Noise-Related Fairness Inventory (fAIR-In).

Aircraft noise causes a variety of negative health consequences, and annoyance is a central factor mediating stress-related health risks. Non-acoustic factors play an important role in the experience of annoyance where the aspect of fairness is assumed to be a vital component. This paper describes the development of the Aircraft Noise-related Fairness Inventory (fAIR-In) and examines its factorial validity, construct validity and predictive validity. The development of the questionnaire included expert consultations, statements from airport residents and a large-scale online survey around three German airports (N = 1367). Its items cover distributive, procedural, informational and interpersonal fairness. Via mailshot, almost 100,000 flyers were sent out in more (>55 dB(A) Lden)- and less (≤55 dB(A) Lden)-aircraft-noise-exposed areas around Cologne-Bonn, Dusseldorf and Dortmund Airport. Thirty-two items were carefully selected considering reliability, theoretical importance and factor loading calculated via exploratory factor analysis (EFA), with all facets achieving high internal consistency (α = 0.89 to 0.92). The factorial validity, analyzed via a confirmatory factor analysis (CFA), revealed that viewing distributive, procedural, informational and interpersonal fairness as distinct factors produced a better fit to the data than other categorizations with fewer factors. The fAIR-In shows adequate results in terms of construct validity and excellent results in terms of the predictive validity of annoyance by aircraft noise (r = -0.53 to r = -0.68), acceptance of airports and air traffic (r = 0.46 to r = 0.59) and willingness to protest (r = -0.28 to r = -0.46). The fAIR-In provides airport managers with a reliable, valid and easy-to-use tool to design, monitor and evaluate efforts to improve the neighborliness between an airport and its residents.

Early environmental quality and life-course mental health effects: The Equal-Life project.

BACKGROUND: There is increasing evidence that a complex interplay of factors within environments in which children grows up, contributes to children's suboptimal mental health and cognitive development. The concept of the life-course exposome helps to study the impact of the physical and social environment, including social inequities, on cognitive development and mental health over time. METHODS: Equal-Life develops and tests combined exposures and their effects on children's mental health and cognitive development. Data from eight birth-cohorts and three school studies (N = 240.000) linked to exposure data, will provide insights and policy guidance into aspects of physical and social exposures hitherto untapped, at different scale levels and timeframes, while accounting for social inequities. Reasoning from the outcome point of view, relevant stakeholders participate in the formulation and validation of research questions, and in the formulation of environmental hazards. Exposure assessment combines GIS-based environmental indicators with omics approaches and new data sources, forming the early-life exposome. Statistical tools integrate data at different spatial and temporal granularity and combine exploratory machine learning models with hypothesis-driven causal modeling. CONCLUSIONS: Equal-Life contributes to the development and utilization of the exposome concept by (1) integrating the internal, physical and social exposomes, (2) studying a distinct set of life-course effects on a child's development and mental health (3) characterizing the child's environment at different developmental stages and in different activity spaces, (4) looking at supportive environments for child development, rather than merely pollutants, and (5) combining physical, social indicators with novel effect markers and using new data sources describing child activity patterns and environments.

A measurement model for general noise reaction in response to aircraft noise.

In this paper a measurement model for general noise reaction (GNR) in response to aircraft noise is developed to assess the performance of aircraft noise annoyance and a direct measure of general reaction as indicators of this concept. For this purpose GNR is conceptualized as a superordinate latent construct underlying particular manifestations. This conceptualization is empirically tested through estimation of a second-order factor model. Data from a community survey at Frankfurt Airport are used for this purpose (N=2206). The data fit the hypothesized factor structure well and support the conceptualization of GNR as a superordinate construct. It is concluded that noise annoyance and a direct measure of general reaction to noise capture a large part of the negative feelings and emotions in response to aircraft noise but are unable to capture all relevant variance. The paper concludes with recommendations for the valid measurement of community reaction and several directions for further research.

Aircraft Noise Distribution as a Fairness Dilemma-A Review of Aircraft Noise through the Lens of Social Justice Research.

Aircraft noise exposure is a health risk and there is evidence that noise annoyance partly mediates the association between noise exposure and stress-related health risks. Thus, approaches to reduce annoyance may be beneficial for health. Annoyance is influenced by manifold non-acoustic factors and perceiving a fair and trustful relationship between the airport and its residents may be one of them. The distribution of aircraft noise exposure can be regarded as a fairness dilemma: while residents living near an airport may seem to have some advantages, the majority of residents living under certain flight routes or in their immediate proximity suffer from the disadvantages of the airport, especially the noise. Moreover, a dilemma exists between the airport's beneficial economic impact for a region and the physical and psychological integrity of residents. Aircraft noise exposure through the lens of social justice research can help to improve our understanding of noise annoyance. Research indicates that the fairness perceptions of the parties involved can be enhanced by (a) improving individual cost-benefit ratios, (b) providing a fair procedure for deciding upon the noise distribution, and (c) implementing fair social interaction with residents. Based on the review of evidence from social justice research, we derive recommendations on how fairness aspects can be integrated into aircraft noise management with the purpose of improving the relationship between the airport and its residents, to reduce annoyance, and to enhance the acceptance of local aviation and the airport as a neighbor.

Pooling and Comparing Noise Annoyance Scores and "High Annoyance" (HA) Responses on the 5-Point and 11-Point Scales: Principles and Practical Advice.

The use of different noise annoyance scales across studies and socio-acoustic surveys, in particular the popular 5-point verbal and 11-point numerical scales, has made the evaluation, comparison, and pooling of noise annoyance responses among studies a taxing issue. This is particularly the case when "high annoyance" (HA) responses need to be compared and when the original studies used different scales; thus, there are different so-called cutoff points that define the part of the scale that indicates the HA status. This paper provides practical guidance on pooling and comparing the respective annoyance data in both the linear and logistic regression context in a statistically adequate manner. It caters to researchers who want to carry out pooled analyses on annoyance data that have been collected on different scales or need to compare exposure-HA relationships between the 5-point and 11-point scales. The necessary simulation of a cutoff point non-native to an original scale can be achieved with a random assignment approach, which is exemplified in the paper using original response data from a range of recent noise annoyance surveys. A code example in the R language is provided for easy implementation of the pertinent procedures with one's own survey data. Lastly, the not insignificant limitations of combining and/or comparing responses from different noise annoyance scales are discussed.

Contributors to Neighbour Noise Annoyance.

Noise from neighbours has been shown to be one of the most noise annoying sources in Germany, but research on the influencing factors for the annoyance ratings is scarce. Therefore, we investigated whether different personal and contextual (social, physical) factors contribute to neighbour noise annoyance to better understand the neighbour noise annoyance situation. A population-representative survey in four areas in Germany was conducted, with each area further stratified according to their density of agglomeration (inner city, urban outskirt, rural area). Randomly selected residents from each area were invited by mail to participate in the study, either online or via a paper-pencil mode. Noise annoyance was assessed for different noise sources (e.g., neighbourhood, road, railway, aircrafts, different types of industry). In total, 1973 questionnaires were completed. We identified several factors to be predictive of neighbour noise annoyance: satisfaction with the neighbourhood, relationship with neighbours, residential satisfaction, noise sensitivity, and density of agglomeration for people living in the inner city in comparison to rural areas. Particularly, social aspects such as the relationship with neighbours and satisfaction with the neighbourhood have been shown to affect neighbour noise annoyance.

Defining pathways to healthy sustainable urban development.

Goals and pathways to achieve sustainable urban development have multiple interlinkages with human health and wellbeing. However, these interlinkages have not been examined in depth in recent discussions on urban sustainability and global urban science. This paper fills that gap by elaborating in detail the multiple links between urban sustainability and human health and by mapping research gaps at the interface of health and urban sustainability sciences. As researchers from a broad range of disciplines, we aimed to: 1) define the process of urbanization, highlighting distinctions from related concepts to support improved conceptual rigour in health research; 2) review the evidence linking health with urbanization, urbanicity, and cities and identify cross-cutting issues; and 3) highlight new research approaches needed to study complex urban systems and their links with health. This novel, comprehensive knowledge synthesis addresses issue of interest across multiple disciplines. Our review of concepts of urban development should be of particular value to researchers and practitioners in the health sciences, while our review of the links between urban environments and health should be of particular interest to those outside of public health. We identify specific actions to promote health through sustainable urban development that leaves no one behind, including: integrated planning; evidence-informed policy-making; and monitoring the implementation of policies. We also highlight the critical role of effective governance and equity-driven planning in progress towards sustainable, healthy, and just urban development.

The associations between noise sensitivity, reported physical and mental health, perceived environmental quality, and noise annoyance.

One hundred and ninety residents around Frankfurt Airport (46% female; 17-80 years) were interviewed concerning noise annoyance due to transportation noise (aircraft, road traffic), perceived mental and physical health, perceived environmental quality, and noise sensitivity. The aim of the analyses was to test whether noise sensitivity reflects partly general environmental sensitivity and is associated with an elevated susceptibility for the perception of mental and physical health. In this study, the reported physical and mental health variables were not associated with noise exposure but with noise annoyance, and were interpreted to reflect nonspecific codeterminants of annoyance rather than noise effects. Noise sensitivity was found to influence total noise annoyance and aircraft noise annoyance but to a lesser degree annoyance due to road traffic noise. Noise sensitivity was associated with reported physical health, but not with reported mental health. Noise-sensitive persons reported poorer environmental quality in their residential area than less sensitive persons in particular with regard to air traffic (including the facets noise, pollution, and contaminations) and quietness. Other aspects of the perceived quality of the environment were scarcely associated with noise sensitivity. This indicates that noise sensitivity is more specific and a reliable predictor of responses to noise from the dominant source (in this case air traffic) rather than a predictor of the individual perception of the environmental quality in general.

Comment on Gjestland, T. A Systematic Review of the Basis for WHO's New Recommendation for Limiting Aircraft Noise Annoyance. Int. J. Env. Res. Pub. Health 2018, 15, 2717.

In his recent discussion paper in this journal, Truls Gjestland attempts a "systematic review", as he calls it, of the evidence base for aircraft noise annoyance, consolidated in a meta-analysis by Guski et al. that informed the recommended guideline value of 45 dB Lden in the recently published World Health Organization (WHO) Environmental Noise Guidelines. He questions the validity of the presented evidence, as "some of the referenced studies have not been conducted according to standardized methods, and the selection of respondents is not representative of the general airport population." Gjestland maintains that the new WHO Guidelines are based on a questionable selection of existing aircraft noise studies. Our reply comments on the arguments of Gjestland and refutes most of his critique.

The Development of a Multiple-Item Annoyance Scale (MIAS) for Transportation Noise Annoyance.

In 2001, Team#6 of the International Commission on Biological Effects of Noise (ICBEN) recommended the use of two single international standardised questions and response scales. This recommendation has been widely accepted in the scientific community. Nevertheless, annoyance can be regarded as a multidimensional construct comprising the three elements: (1) experience of an often repeated noise-related disturbance and the behavioural response to cope with it, (2) an emotional/attitudinal response to the sound and its disturbing impact, and (3) the perceived control or coping capacity with regard to the noise situation. The psychometric properties of items reflecting these three elements have been explored for aircraft noise annoyance. Analyses were conducted using data of the NORAH-Study (Noise-Related Annoyance, Cognition, and Health), and a multi-item noise annoyance scale (MIAS) has been developed and tested post hoc by using a stepwise process (exploratory and confirmatory factor analyses). Preliminary results were presented to the 12th ICBEN Congress in 2017. In this study, the validation of MIAS is done for aircraft noise and extended to railway and road traffic noise. The results largely confirm the concept of MIAS as a second-order construct of annoyance for all of the investigated transportation noise sources; however, improvements can be made, in particular with regard to items addressing the perceived coping capacity.

WHO Environmental Noise Guidelines for the European Region: A Systematic Review on Environmental Noise and Annoyance.

Background: This paper describes a systematic review and meta-analyses on effects of environmental noise on annoyance. The noise sources include aircraft, road, and rail transportation noise as well as wind turbines and noise source combinations. Objectives: Update knowledge about effects of environmental noise on people living in the vicinity of noise sources. Methods: Eligible were published studies (2000-2014) providing comparable acoustical and social survey data including exposure-response functions between standard indicators of noise exposure and standard annoyance responses. The systematic literature search in 20 data bases resulted in 62 studies, of which 57 were used for quantitative meta-analyses. By means of questionnaires sent to the study authors, additional study data were obtained. Risk of bias was assessed by means of study characteristics for individual studies and by funnel plots to assess the risk of publication bias. Main Results: Tentative exposure-response relations for percent highly annoyed residents (%HA) in relation to noise levels for aircraft, road, rail, wind turbine and noise source combinations are presented as well as meta-analyses of correlations between noise levels and annoyance raw scores, and the OR for increase of %HA with increasing noise levels. Quality of evidence was assessed using the GRADE terminology. The evidence of exposure-response relations between noise levels and %HA is moderate (aircraft and railway) or low (road traffic and wind turbines). The evidence of correlations between noise levels and annoyance raw scores is high (aircraft and railway) or moderate (road traffic and wind turbines). The evidence of ORs representing the %HA increase by a certain noise level increase is moderate (aircraft noise), moderate/high (road and railway traffic), and low (wind turbines). Strengths and Limitations: The strength of the evidence is seen in the large total sample size encompassing the included studies (e.g., 18,947 participants in aircraft noise studies). Main limitations are due to the variance in the definition of noise levels and %HA. Interpretation: The increase of %HA in newer studies of aircraft, road and railway noise at comparable Lden levels of earlier studies point to the necessity of adjusting noise limit recommendations. Funding: The review was funded by WHO Europe.

The Combined Effects of Aircraft and Road Traffic Noise and Aircraft and Railway Noise on Noise Annoyance-An Analysis in the Context of the Joint Research Initiative NORAH.

The Noise Related Annoyance Cognition and Health (NORAH) research initiative is one of the most extensive studies on the physiological and psychological long-term effects of transportation noise in Europe. It includes research on the quality of life and annoyance as well as cardiovascular effects, sleep disturbance, breast cancer, blood pressure, depression and the cognitive development of children. Within the realm of the annoyance module of the study approximately 10,000 residents of the Rhine-Main district were surveyed on the combined effects of transportation noise. This included combined noise from aircraft and road traffic noise (N = 4905), or aircraft and railway noise (N = 4777). Results show that judgment of the total noise annoyance of participants was strongly determined by the sound source which was judged as more annoying (in this case aircraft noise). To a lesser extent, the average sound pressure level of the two present sources was also of relevance.

Effects of Scale, Question Location, Order of Response Alternatives, and Season on Self-Reported Noise Annoyance Using ICBEN Scales: A Field Experiment.

The type of noise annoyance scale and aspects of its presentation such as response format or location within a questionnaire and other contextual factors may affect self-reported noise annoyance. By means of a balanced experimental design, the effect of type of annoyance question and corresponding scale (5-point verbal vs. 11-point numerical ICBEN (International Commission on Biological Effects of Noise) scale), presentation order of scale points (ascending vs. descending), question location (early vs. late within the questionnaire), and survey season (autumn vs. spring) on reported road traffic noise annoyance was investigated in a postal survey with a stratified random sample of 2386 Swiss residents. Our results showed that early appearance of annoyance questions was significantly associated with higher annoyance scores. Questionnaires filled out in autumn were associated with a significantly higher annoyance rating than in the springtime. No effect was found for the order of response alternatives. Standardized average annoyance scores were slightly higher using the 11-point numerical scale whereas the percentage of highly annoyed respondents was higher based on the 5-point scale, using common cutoff points. In conclusion, placement and presentation of annoyance questions within a questionnaire, as well as the time of the year a survey is carried out, have small but demonstrable effects on the degree of self-reported noise annoyance.

European longitudinal study on the relationship between adolescents' alcohol marketing exposure and alcohol use.

BACKGROUND AND AIMS: This is the first study to examine the effect of alcohol marketing exposure on adolescents' drinking in a cross-national context. The aim was to examine reciprocal processes between exposure to a wide range of alcohol marketing types and adolescent drinking, controlled for non-alcohol branded media exposure. DESIGN: Prospective observational study (11-12- and 14-17-month intervals), using a three-wave autoregressive cross-lagged model. SETTING: School-based sample in 181 state-funded schools in Germany, Italy, Netherlands, Poland. PARTICIPANTS: A total of 9075 eligible respondents participated in the survey (mean age 14 years, 49.5% male. MEASUREMENTS: Adolescents reported their frequency of past-month drinking and binge drinking. Alcohol marketing exposure was measured by a latent variable with 13 items measuring exposure to online alcohol marketing, televised alcohol advertising, alcohol sport sponsorship, music event/festival sponsorship, ownership alcohol-branded promotional items, reception of free samples and exposure to price offers. Confounders were age, gender, education, country, internet use, exposure to non-alcohol sponsored football championships and television programmes without alcohol commercials. FINDINGS: The analyses showed one-directional long-term effects of alcohol marketing exposure on drinking (exposure T1 on drinking T2: ß = 0.420 (0.058), P < 0.001, 95% confidence interval (CI) = 0.324-0.515; exposure T2 on drinking T3: ß = 0.200 (0.044), P < 0.001, 95% CI = 0.127-0.272; drinking T1 and drinking T2 on exposure: P > 0.05). Similar results were found in the binge drinking model (exposure T1 on binge T2: ß = 0.409 (0.054), P < 0.001, 95% CI = 0.320-0.499; exposure T2 on binge T3: ß = 0.168 (0.050), P = 0.001, 95% CI = 0.086-0.250; binge T1 and binge T2 on exposure: P > 0.05). CONCLUSIONS: There appears to be a one-way effect of alcohol marketing exposure on adolescents' alcohol use over time, which cannot be explained by either previous drinking or exposure to non-alcohol-branded marketing.

Night-time Noise Annoyance: State of the Art.

The annoyance-reaction is one of the central variables in noise research. After an introduction to different concepts and definitions of noise annoyance different scales of how noise annoyance can be measured are shown. The question is discussed whether disturbance effects of noise at different times of day are given. To clarify this problem, the results of a series of actual German noise studies are reported. In these studies differences between day- and night-time annoyance are found depending on the sound sources. For the case of road traffic noise no differences between day and night-time annoyance were found. In contrast, annoyance reactions are related to the time of day for railway and air traffic noise. Especially for aircraft noise, above a Leq of 50 dB(A) night-time annoyance rises faster than day-time annoyance. The effects are discussed in the frame of a cognitive model of noise annoyance. It is argued that annoyance judgements are based on an internal representation of the noise situation. Part of this representation are the event characteristics of the sound sources and their estimated impacts for disturbances at different times of day.

Aircraft noise and quality of life around Frankfurt Airport.

In a survey of 2,312 residents living near Frankfurt Airport aircraft noise annoyance and disturbances as well as environmental (EQoL) and health-related quality of life (HQoL) were assessed and compared with data on exposure due to aircraft, road traffic, and railway noise. Results indicate higher noise annoyance than predicted from general exposure-response curves. Beside aircraft sound levels source-related attitudes were associated with reactions to aircraft noise. Furthermore, aircraft noise affected EQoL in general, although to a much smaller extent. HQoL was associated with aircraft noise annoyance, noise sensitivity and partly with aircraft noise exposure, in particular in the subgroup of multimorbid residents. The results suggest a recursive relationship between noise and health, yet this cannot be tested in cross-sectional studies. Longitudinal studies would be recommendable to get more insight in the causal paths underlying the noise-health relationship.