Determining the Public Health Impact of Climate Change: A National Study Using a Health Impact Assessment Approach in Wales.

Objective: Climate change is recognised as the biggest threat to global health of the 21st century and impacts on health and wellbeing through a range of factors. Due to this, the need to take action in order to protect population health and wellbeing is becoming ever more urgent. Methods: In 2019, Public Health Wales carried out a comprehensive mixed-method Health Impact Assessment (HIA) of climate change. Unlike other risk assessments, it appraised the potential impact of climate change on health and inequalities in Wales through participatory workshops, stakeholder consultations, systematic literature reviews and case studies. Results: The HIA findings indicate potential impacts across the wider determinants of health and wellbeing. For example, air quality, excess heat/cold, flooding, economic productivity, infrastructure, and community resilience. A range of impacts were identified across population groups, settings, and geographical areas. Conclusion: These findings can inform decision-makers to prepare for climate change plans and policies using an evidence-informed approach. The work has demonstrated the value of a HIA approach by mobilising a range of evidence through a transparent process, resulting in transferrable learning for others.

Risk-based public health impact assessment for drinking water contamination emergencies.

Chemical spills in surface waters pose a significant threat to public health and the environment. This study investigates the public health impacts associated with organic chemical spill emergencies and explores timely countermeasures deployable by drinking water facilities. Using a dynamic model of a typical multi-sourced New England drinking water treatment facility and its distribution network, this study assesses the impacts of various countermeasure deployment scenarios, including source switching, enhanced coagulation via poly­aluminum chloride (PACl), addition of powdered activated carbon (PAC), and temporary system shutdown. This study reveals that the deployment of multiple countermeasures yields the most significant reduction in total public health impacts, regardless of the demand and supply availability. With the combination PAC deployed first with other countermeasures proving to be the most effective strategies, followed by the combination of facility shutdowns. By understanding the potential public health impacts and evaluating the effectiveness of countermeasures, authorities can develop proactive plans, secure additional funding, and enhance their capacity to mitigate the consequences of such events. These insights contribute to safeguarding public health and improving the resilience of drinking water systems in the face of the ever-growing threat of chemical spills.

Health implications of urban tree canopy policy scenarios in Denver and Phoenix: A quantitative health impact assessment.

BACKGROUND: Urban tree canopy (UTC) goals are a popular policy to increase urban vegetation, support climate strategies, and encourage a healthy environment. Health studies related to UTC are needed across cities to support evidence-based decision-making. METHODS: We used a quantitative Health Impact Assessment (HIA) to model the annual number of premature deaths prevented, and the number of stroke and dementia cases, under UTC goals in Denver, Colorado, and Phoenix, Arizona, USA, using standing policy goals (20% and 25% UTC, respectively) and 50% ("half-way") attainment scenarios from current levels (16.5% and 13% UTC, respectively), using publicly accessible national datasets, and a proportional representation of UTC change to standardize across methodologies. We estimated UTC health impacts by relating UTC with scenario-based changes in the Normalized Difference Vegetation Index (NDVI) and considered health equity in UTC distributions and benefits. RESULTS: We projected that at 2020 populations, uniform 20% UTC attainment across Denver block groups would avert 200 (95% uncertainty interval: (UI) 100, 306) annual premature deaths among adults 18 and older, along with 4.1 (95% UI: 2.2, 6.7) annual cases of stroke (adults ≥35), and 2.6 (95% UI: 1.5, 4.1) cases of dementia (adults ≥65), with "halfway" attainment from current levels (16.5% UTC) capturing ∼64% of these benefits. In Phoenix, uniform 25% UTC would annually prevent 368 (95% UI: 181, 558) premature deaths, 8.7 (95% UI: 4.7, 13.9) cases of stroke, and 5,1 (95% UI: 2.9, 8.0) of dementia, with the "halfway" scenario (17% UTC) achieving ∼44% of these results. Both cities saw significantly different greenspace exposures and health outcomes by socioeconomic vulnerability. Denver had more spatially and socioeconomically heterogeneous projected health benefits than Phoenix. CONCLUSIONS: Implementing UTC goals can prevent excess mortality and chronic diseases among urban residents. UTC goals can be used as a health promotion and prevention tool.

Wood heater smoke and mortality in the Australian Capital Territory: a rapid health impact assessment.

OBJECTIVES: To estimate the number of deaths and the cost of deaths attributable to wood heater smoke in the Australian Capital Territory. STUDY DESIGN: Rapid health impact assessment, based on fine particulate matter (PM2.5 ) data from three outdoor air pollution monitors and published exposure-response functions for natural cause mortality attributed to PM2.5 exposure. SETTING: Australian Capital Territory (population, 2021: 454 000), 2016-2018, 2021, and 2022 (2019 and 2020 excluded because of the impact of extreme bushfires on air quality). MAIN OUTCOME MEASURES: Proportion of PM2.5 exposure attributable to wood heaters; numbers of deaths and associated cost of deaths (based on the value of statistical life: $5.3 million) attributable to wood heater smoke. RESULTS: Wood heater emissions contributed an estimated 1.16-1.73 µg/m3 to the annual mean PM2.5 concentration during the three colder years (2017, 2018, 2021), or 17-25% of annual mean exposure, and 0.72 µg/m3 (15%) or 0.89 µg/m3 (13%) during the two milder years (2016, 2022). Using the most conservative exposure-response function, the estimated annual number of deaths attributable to wood heater smoke was 17-26 during the colder three years and 11-15 deaths during the milder two years. Using the least conservative exposure-response function, an estimated 43-63 deaths per year (colder years) and 26-36 deaths per year (milder years) were attributable to wood heater smoke. The estimated annual equivalent cost of deaths was $57-136 million (most conservative exposure-response function) and $140-333 million (least conservative exposure-response function). CONCLUSIONS: The estimated annual number of deaths in the ACT attributable to wood heater PM2.5 pollution is similar to that attributed to the extreme smoke of the 2019-20 Black Summer bushfires. The number of wood heaters should be reduced by banning new installations and phasing out existing units in urban and suburban areas.

Impact of a research-action on vaccination indicators in the state of Minas Gerais, Brazil / Impacto de uma pesquisa-ação nos indicadores vacinais em Minas Gerais

ABSTRACT OBJECTIVE Analyze the impact of the state research-action project on immunization indicators (vaccination coverage - VC, homogeneity of vaccination coverage - HVC, dropout rate - DR, and risk rating) before and after the intervention in municipalities and priority Regional Health Administrations/Regional Health Superintendencies (RHA/RHS). METHODS The state research-action project was a before-after community clinical trial conducted in 212 municipalities belonging to eight RHA/RHS in the state of Minas Gerais, Brazil. The study sample comprised RHA/RHS with a decreasing trend for routine vaccination coverage in children under one year from 2015 to 2020. This study used secondary VC and DR data from 10 immunobiologicals recommended for children younger than two years from January to December 2021 (pre-intervention period, prior to the state research-action project) and from January to December 2022 (post-intervention period). The categorical variables were presented in proportions, and initially, a comparison was made between those of DR, HVC, and the risk rating for the transmission of vaccine-preventable diseases, according to the two periods (2021 and 2022), using the McNemar test. RESULTS All immunization indicators increased after conducting the research-action project. In 2021, 80.66% of the state's municipalities had a risk rating for the transmission of vaccine-preventable diseases as "high and very high." In 2022, the value reduced to 68.40%. CONCLUSIONS Risk rating for the transmission of vaccine-preventable diseases is an important mechanism to assist managers in defining priorities. The state research-action project used a method that enabled the construction and execution of unique action plans for each municipality, directing the improvement of immunization indicators in the state.

RESUMO OBJETIVO Analisar o impacto do projeto estadual de pesquisa-ação nos indicadores de imunização (coberturas vacinais - CV, homogeneidade de cobertura vacinal - HCV, taxa de abandono - TA e classificação de risco) antes e após a intervenção em municípios e Gerências Regionais de Saúde/Superintendências Regionais de Saúde (GRS/SRS) prioritários. MÉTODOS O projeto estadual de pesquisa-ação foi um ensaio clínico comunitário, do tipo antes-depois, realizado em 212 municípios pertencentes a oito GRS/SRS do estado de Minas Gerais, Brasil. Compuseram a amostra do estudo as SRS/GRS com tendência decrescente para a cobertura vacinal de rotina em crianças menores de 1 ano, no período de 2015 a 2020. Neste estudo, foram utilizados dados secundários de CV e TA de 10 imunobiológicos recomendados para crianças menores de 2 anos, no período de janeiro a dezembro de 2021 (período pré-intervenção, anterior ao projeto estadual de pesquisa-ação) e de janeiro a dezembro de 2022 (período pós-intervenção). As variáveis categóricas foram apresentadas em proporções e, inicialmente, realizou-se a comparação entre as de TA, HCV e a classificação de risco para a transmissão de doenças imunopreveníveis, segundo os dois períodos (2021 e 2022), utilizando-se o teste McNemar. RESULTADOS Observou-se um aumento de todos os indicadores de imunização após a realização do projeto de pesquisa-ação. No ano de 2021, 80,66% dos municípios do estado tiveram a classificação de risco para transmissão de doenças imunopreveníveis como "alto e muito alto risco". Em 2022, o valor foi reduzido para 68,40%. CONCLUSÕES A classificação de risco para transmissão de doenças imunopreveníveis é um mecanismo importante para auxiliar os gestores na definição de prioridades. O projeto estadual de pesquisa-ação empregou um método que possibilitou a construção e a execução de planos de ação singulares a cada município, direcionando a melhoria dos indicadores de imunização no estado.

Urban green spaces and behavioral and cognitive development in children: A health impact assessment of the Barcelona "Eixos Verds" Plan (Green Axis Plan).

BACKGROUND: Urban environments lack natural features, while nature exposure in cities has been associated with health benefits, including children's neurodevelopment. Through extensive street greening, Barcelona's Eixos Verds (Green Axis) Plan enhances safety, environment, and climate resilience. We aimed to assess the Eixos Verds Plan's potential impact on children's behavioral and cognitive development due to the increased green space expected under the Eixos Verds implementation. METHODS: We performed a quantitative health impact assessment for Barcelona children at census-tract level (n = 1068). We assessed the Eixos Verds Plan's impact by comparing baseline green space distribution with the proposed plan, translating it into percentage green area (%GA) and Normalized Difference Vegetation Index (NDVI). By combining these exposure metrics with child-specific risk estimates and population data, we estimated potential improvements in children's behavioral and cognitive development due to full Eixos Verds implementation. RESULTS: With the full Eixos Verds implementation, citywide, %GA increased by 6.9% (IQR: 6.4%; range: 0-23.1%) and NDVI by 0.065 (IQR: 0.083; range: 0.000-0.194). Child behavioral and cognitive development outcomes are expected to improve compared to the baseline. Based on NDVI increases, children's Total Difficulties and Hyperactivity/Inattention scores, based on the Strengths and Difficulties Questionnaire (SDQ), are projected to decrease by 5% (95% CI: 0-15%) and 6% (95% CI: 0-17%). Working Memory and Superior Working Memory scores are expected to increase by 4% and 5%, respectively, based on the computerized n-back test, while the Inattentiveness score could be reduced by 1%, based on the computerized attentional test (ANT). INTERPRETATION: Urban greening as planning tool can improve behavioral and cognitive development in city children. Methods and results of our study are applicable to many cities worldwide, and similar results for children of real-life urban greening interventions can be expected.

Developing a climate change inequality health impact assessment for health services.

OBJECTIVES: To develop a Climate Change Inequality Health Impact Assessment (CCIHIA) framework for health services; to provide a systematic process for assessing potential unequal health impacts of climate change on vulnerable and marginalised populations and places; to support effective planning to address these impacts; and to develop contextually appropriate local strategies. Type of program: A collaborative interdisciplinary scoping research project involving two universities and two local health districts (LHDs) in New South Wales (NSW) to develop a CCIHIA framework. This work builds upon the health impact assessment (HIA) approach, which systematically assesses proposals' potential health and equity impacts by involving stakeholders in developing responses. METHODS: The project involved four main activities: understanding stakeholder requirements; conceptualising climate change vulnerability; considering the role of health services; and integrating findings into a conceptual framework. RESULTS: Stakeholders identified key functions that should be addressed across the framing, process and utility of the CCIHIA framework. The resulting conceptual framework outlines contexts and social stratification, the differential impacts of climate change (including factors influencing unequal impacts) and the health system's position, and also identifies key potential points of intervention. LESSONS LEARNT: The challenge of addressing the complexity of factors and resulting health impacts is reflected within the CCIHIA framework. While there are many intervention points within this framework for health services to address, many factors influencing unequal impacts are created outside the health sector's direct control. The framework's development process reflected the focus on collaboration and the interdisciplinary nature of climate change response. Ultimately, the CCIHIA framework is an assessment tool and an approach for prioritising inclusive, cross-cutting, multisector working, and problem-solving.

Health Impact Assessment in protected areas: a proposal for urban contexts in Brazil.

The use of Health Impact Assessment (HIA) in the establishment of an urban protected area can enhance the positive impacts and mitigate the negative impacts resulting from its implementation. Brazil hosts some of the most important biodiversity hotspots in the world and the HIA may benefit biodiversity and human health. These areas are commonly created without any preceding survey to assess their impacts on health. Protected areas located in urban zones are essential to maintain environmental balance and quality of life in cities. It promotes positive impacts on health, providing ecosystem services and salutogenic benefits. However, they can generate negative impacts such as the violation of human rights, property speculation, spread of vectorial diseases, and psychosocial stress. Based on the identification of the potential impacts of urban protected areas on health and best practices, this qualitative and exploratory study justifies the use of HIA in urban protected areas, especially in the Brazil, and indicates the main elements for the construction of a methodological approach to contribute to the Sustainable Development Goals and one of its alternatives, the Buen Vivir approach.

Health Equity Impact Assessment (HEIA) reporting tool: developing a checklist for policymakers.

INTRODUCTION: Health Equity Impact Assessment (HEIA) is a decision support tool that shows users how a new program, policy, or innovation affects health equity in different population groups. Various HEIA reporting and dissemination tools are available, nevertheless, a practical standard tool to present the results of HEIA in an appropriate period to policymakers is lacking. This work reports the development of a tool (a checklist) for HEIA reporting at the decision-making level, aiming to promote the application of HEIA evidence for improving health equity. METHODS: This is a mixed-method study that was carried out over four stages in 2022-2023: 1) identifying HEIA models, checklists, and reporting instruments; 2) development of the initial HEIA reporting checklist; 3) checklist validation; and 4) piloting the checklist. We also analyzed the Face, CVR, and CVI validity of the tool. RESULTS: We developed the initial checklist through analysis of 53 included studies and the opinions of experts. The final checklist comprised five sections: policy introduction (eight subsections), managing the HEIA of policy (seven subsections), scope of the affected population (three subsections), HEIA results (seven subsections), and recommendations (three subsections). CONCLUSION: Needs assessment, monitoring during implementation, health impact assessment, and other tools such as monitoring outcome reports, appraisals, and checklists are all methods for assessing health equity impact. Other equity-focused indicators, such as the equity lens and equity appraisal, may have slightly different goals than the HEIA. Similarly, the formats for presenting and publishing HEIA reports might vary, depending on the target population and the importance of the report.

Current status and influencing factors of policy identification in health impact assessment: a case study of Zhejiang Province.

BACKGROUND: Health impact assessment (HIA) is a procedure, method and tool for evaluating the potential health impacts of policies, plans and construction projects, as well as the distribution of these impacts on population. Majority of international studies on health impact assessment have focussed on conceptual papers or case evaluations, neglecting participants' views on policies. METHODS: A semi-structured interview with 30 health impact assessment experts was employed in this study, and the Nvivo software was utilized to analyse factors that influence policy identification. Subsequently, a multi-stage stratified random sampling method was adopted to survey 655 pilot staff members involved in health impact assessment in Zhejiang Province. Descriptive statistics were used to describe the current status and identify the factors influencing policy identification. In addition, hierarchical linear regression analysis and structural equation modelling were employed to determine the relationship between policy identification and influencing factors. RESULTS: Statistically significant differences were found among participants in the level of identification of policies across three dimensions. The policy sentiment dimension had the highest score (4.137 ± 0.664), followed by policy cognition (4.075 ± 0.632) and policy evaluation (3.631 ± 0.797) dimensions. Subject trust had a positive impact on policy cognition (ß = 0.503, P < 0.001), policy sentiment (ß = 0.504, P < 0.001) and policy evaluation (ß = 0.465, P < 0.001). Procedural justice had a positive impact on policy sentiment (ß = 0.085, P < 0.01) and policy evaluation (ß = 0.084, P < 0.05), but not policy cognition (ß = 0.056, P > 0.05). Policy identification is influenced by age and average monthly salary among other factors. CONCLUSION: These results highlight the importance of subjective trust and procedural justice in policy identification of health impact assessment. They provide valuable insights to developing interventions to overcome barriers to the implementation and enhancement of global identification of policies. Going forward, cross-sectoral synergies, enhanced international communication and training to increase participants' trust in the policy should be optimized to improve health impact assessment. Additional measures should be taken, such as ensuring seamless communication channels, embedding health impact assessment in administrative mechanisms, and establishing strong oversight and grievance mechanisms to improve fairness and transparency in the implementation and results of health impact assessment.

[The mortality cost of carbon dioxide emissions from a steel plant in Southern Italy: a climate change health impact assessment]. / Il "mortality cost" delle emissioni di CO2 di uno stabilimento siderurgico nel Sud Italia: una valutazione degli impatti sanitari derivanti dal cambiamento climatico.

OBJECTIVES: to quantify the temperature-related global health impacts of the Taranto steel plant CO2e emissions. DESIGN: using the risk functions available in the literature, a prospective global health impact assessment of the marginal CO2e emissions declared by the steel plant for 2020 was conducted. SETTING AND PARTICIPANTS: world population in the period 2020-2100. MAIN OUTCOMES MEASURES: deaths in the period 2020-2100 attributable to the marginal CO2e emitted by the Taranto steel plant in 2020. RESULTS: considering the central estimates in the baseline emission scenario (4.1°C warming by 2100), the Taranto steel plant 2020 CO2e emissions will cause 1,876 deaths worldwide between 2020 and 2100. The largest part will be attributable to steelmaking processes, accounting for 1,093 deaths. The same emissions will cause 5.56 × 10-4 deaths worldwide between 2020 and 2100 per tonne of steel produced in 2020, i.e. one death for every 1,799 tonnes of steel. If the 2020 CO2e emissions of the steel plant had been reduced by 25%, 50% or 75%, the deaths avoided in the world in the period 2020-2100 would have been 469, 938 and 1,407 respectively. CONCLUSIONS: estimates predict a probably significant mortality impact worldwide by the end of the century associated with the greenhouse gases emissions of the Taranto steel plant. Just reducing emissions by 50% in a single year could maybe avoid over 900 deaths worldwide by the end of the century. This confirms the importance of implementing incisive policies to reduce greenhouse gases emissions in all sectors.

Projections of mortality risk attributable to short-term exposure to landscape fire smoke in China, 2021-2100: a health impact assessment study.

BACKGROUND: Landscape fire smoke, including smoke from all vegetation burning in natural and cultural landscapes, remains a threat to the health of the population. However, the future health impacts of landscape fire smoke in China have not been sufficiently investigated. We aimed to estimate the mortality risk attributable to landscape fire-related PM2·5 under different scenarios. METHODS: In this health impact assessment study, we used the projected population and landscape fire-related PM2·5 concentration to calculate deaths attributable to short-term exposure to landscape fire smoke PM2·5 during 2021-2100. We did the analysis in three defined future periods: 2021-40 (near term), 2051-70 (medium term), and 2081-2100 (long term), with 1986-2005 as the historical period. We used fire-specific short-term epidemiological functions with the regional parameters specific to China. We assessed the mortality risks of landscape fire-related smoke and further identified their spatiotemporal distribution under two shared socioeconomic pathway (SSP) scenarios: SSP1-2·6, an optimistic scenario with strict control of carbon emissions, and SSP2-4·5, an intermediate scenario with weaker control of carbon emissions. FINDINGS: The national mortality rate attributable to short-term exposure (ie, a few days) to landscape fire-related PM2·5 is projected to increase compared with historical values. The national deaths attributable to landscape fire smoke PM2·5 could peak in 2021-40, with increases of 28·10% (95% CI 14·08-53·11) under the SSP1-2·6 scenario and 37·38% (14·08-53·11) under the SSP2-4·5 scenario. Deaths would then decrease slightly during 2051-70 and 2081-2100. The provinces with the highest projected number of deaths attributable to landscape fire-related PM2·5 are located in east and south-central China, and those with the largest percentage increase in projected deaths are located in northwest and southwest China. INTERPRETATION: Our results suggest that global warming could increase the contribution of landscape fire smoke to the total PM2·5 concentration, leading to an increase in the mortality rate in China. Our findings could help policy makers implement effective interventions in hotspot areas during different periods to reduce the impact of landscape fire smoke on human health. FUNDING: The National Natural Science Foundation of China, National Key Research and Development Program of China, and the Wellcome Trust.

Health impact assessment after Danio rerio long-term exposure to environmentally relevant concentrations of metformin and guanylurea.

The antidiabetic drug metformin (MET) and its metabolite guanylurea (GUA) have been frequently and ubiquitously detected in surface water. Consequently, there has been a consistent rise in studying the toxicity of MET and GUA in fish over the past decade. Nonetheless, it is noteworthy that no study has assessed the harmful effects both compounds might trigger on fish blood and organs after chronic exposure. Taking into consideration the data above, our research strived to accomplish two primary objectives: Firstly, to assess the effect of comparable concentrations of MET and GUA (1, 40, 100 µg/L) on the liver, gills, gut, and brain of Danio rerio after six months of flow-through exposure. Secondly, to compare the outcomes to identify which compound prompts more significant oxidative stress and apoptosis in organs and blood parameter alterations. Herein, findings indicate that both compounds induced oxidative damage and increased the expression of genes associated with apoptosis (bax, bcl2, p53, and casp3). Chronic exposure to MET and GUA also generated fluctuations in glucose, creatinine, phosphorus, liver enzymes, red and white blood count, hemoglobin, and hematocrit levels. The observed biochemical changes indicate that MET and GUA are responsible for inducing hepatic damage in fish, whereas hematological alterations suggest that both compounds cause anemia. Considering GUA altered to a more considerable extent the values of all endpoints compared to the control group, it is suggested transformation product GUA is more toxic than MET. Moreover, based on the above evidence, it can be inferred that a six-month exposure to MET and GUA can impair REDOX status and generate apoptosis in fish, adversely affecting their essential organs' functioning.

New concentration-response functions for seven morbidity endpoints associated with short-term PM2.5 exposure and their implications for health impact assessment.

BACKGROUND: Morbidity burdens from ambient air pollution are associated with market and non-market costs and are therefore important for policymaking. The estimation of morbidity burdens is based on concentration-response functions (CRFs). Most existing CRFs for short-term exposures to PM2.5 assume a fixed risk estimate as a log-linear function over an extrapolated exposure range, based on evidence primarily from Europe and North America. OBJECTIVES: We revisit these CRFs by performing a systematic review for seven morbidity endpoints previously assessed by the World Health Organization, including data from all available regions. These endpoints include all cardiovascular hospital admission, all respiratory hospital admission, asthma hospital admission and emergency room visit, along with the outcomes that stem from morbidity, such as lost work days, respiratory restricted activity days, and child bronchitis symptom days. METHODS: We estimate CRFs for each endpoint, using both a log-linear model and a nonlinear model that includes additional parameters to better fit evidence from high-exposure regions. We quantify uncertainties associated with these CRFs through randomization and Monte Carlo simulations. RESULTS: The CRFs in this study show reduced model uncertainty compared with previous CRFs in all endpoints. The nonlinear CRFs produce more than doubled global estimates on average, depending on the endpoint. Overall, we assess that our CRFs can be used to provide policy analysis of air pollution impacts at the global scale. It is however important to note that improvement of CRFs requires observations over a wide range of conditions, and current available literature is still limited. DISCUSSION: The higher estimates produced by the nonlinear CRFs indicates the possibility of a large underestimation in current assessments of the morbidity impacts attributable to air pollution. Further studies should be pursued to better constrain the CRFs studied here, and to better characterize the causal relationship between exposures to PM2.5 and morbidity outcomes.

Public health advocacy strategies to influence policy agendas: lessons from a narrative review of success in trade policy.

BACKGROUND: Despite accumulating evidence of the implications of trade policy for public health, trade and health sectors continue to operate largely in silos. Numerous barriers to advancing health have been identified, including the dominance of a neoliberal paradigm, powerful private sector interests, and constraints associated with policymaking processes. Scholars and policy actors have recommended improved governance practices for trade policy, including: greater transparency and accountability; intersectoral collaboration; the use of health impact assessments; South-South networking; and mechanisms for civil society participation. These policy prescriptions have been generated from specific cases, such as the World Trade Organization's Doha Declaration on TRIPS and Public Health or specific instances of trade-related policymaking at the national level. There has not yet been a comprehensive analysis of what enables the elevation of health goals on trade policy agendas. This narrative review seeks to address this gap by collating and analysing known studies across different levels of policymaking and different health issues. RESULTS: Sixty-five studies met the inclusion criteria and were included in the review. Health issues that received attention on trade policy agendas included: access to medicines, food nutrition and food security, tobacco control, non-communicable diseases, access to knowledge, and asbestos harm. This has occurred in instances of domestic and regional policymaking, and in bilateral, regional and global trade negotiations, as well as in trade disputes and challenges. We identified four enabling conditions for elevation of health in trade-related policymaking: favourable media attention; leadership by trade and health ministers; public support; and political party support. We identified six strategies successfully used by advocates to influence these conditions: using and translating multiple forms of evidence, acting in coalitions, strategic framing, leveraging exogenous factors, legal strategy, and shifting forums. CONCLUSION: The analysis demonstrates that while technical evidence is important, political strategy is necessary for elevating health on trade agendas. The analysis provides lessons that can be explored in the wider commercial determinants of health where economic and health interests often collide.

Model Choice for Quantitative Health Impact Assessment and Modelling: An Expert Consultation and Narrative Literature Review.

BACKGROUND: Health impact assessment (HIA) is a widely used process that aims to identify the health impacts, positive or negative, of a policy or intervention that is not necessarily placed in the health sector. Most HIAs are done prospectively and aim to forecast expected health impacts under assumed policy implementation. HIAs may quantitatively and/ or qualitatively assess health impacts, with this study focusing on the former. A variety of quantitative modelling methods exist that are used for forecasting health impacts, however, they differ in application area, data requirements, assumptions, risk modelling, complexities, limitations, strengths, and comprehensibility. We reviewed relevant models, so as to provide public health researchers with considerations for HIA model choice. METHODS: Based on an HIA expert consultation, combined with a narrative literature review, we identified the most relevant models that can be used for health impact forecasting. We narratively and comparatively reviewed the models, according to their fields of application, their configuration and purposes, counterfactual scenarios, underlying assumptions, health risk modelling, limitations and strengths. RESULTS: Seven relevant models for health impacts forecasting were identified, consisting of (i) comparative risk assessment (CRA), (ii) time series analysis (TSA), (iii) compartmental models (CMs), (iv) structural models (SMs), (v) agent-based models (ABMs), (vi) microsimulations (MS), and (vii) artificial intelligence (AI)/machine learning (ML). These models represent a variety in approaches and vary in the fields of HIA application, complexity and comprehensibility. We provide a set of criteria for HIA model choice. Researchers must consider that model input assumptions match the available data and parameter structures, the available resources, and that model outputs match the research question, meet expectations and are comprehensible to end-users. CONCLUSION: The reviewed models have specific characteristics, related to available data and parameter structures, computational implementation, interpretation and comprehensibility, which the researcher should critically consider before HIA model choice.

Health impact assessment for air pollution in the presence of regional variation in effect sizes: The implications of using different meta-analytic approaches.

The estimated health effects of air pollution vary between studies, and this variation is caused by factors associated with the study location, hereafter termed regional heterogeneity. This heterogeneity raises a methodological question as to which studies should be used to estimate risks in a specific region in a health impact assessment. Should one use all studies across the world, or only those in the region of interest? The current study provides novel insight into this question in two ways. Firstly, it presents an up-to-date analysis examining the magnitude of continent-level regional heterogeneity in the short-term health effects of air pollution, using a database of studies collected by Orellano et al. (2020). Secondly, it provides in-depth simulation analyses examining whether existing meta-analyses are likely to be underpowered to identify statistically significant regional heterogeneity, as well as evaluating which meta-analytic technique is best for estimating region-specific estimates. The techniques considered include global and continent-specific (sub-group) random effects meta-analysis and meta-regression, with omnibus statistical tests used to quantify regional heterogeneity. We find statistically significant regional heterogeneity for 4 of the 8 pollutant-outcome pairs considered, comprising NO2, O3 and PM2.5 with all-cause mortality, and PM2.5 with cardiovascular mortality. From the simulation analysis statistically significant regional heterogeneity is more likely to be identified as the number of studies increases (between 3 and 30 in each region were considered), between region heterogeneity increases and within region heterogeneity decreases. Finally, while a sub-group analysis using Cochran's Q test has a higher median power (0.71) than a test based on the moderators' coefficients from meta-regression (0.59) to identify regional heterogeneity, it also has an inflated type-1 error leading to more false positives (median errors of 0.15 compared to 0.09).

Spatial and sector-specific contributions of emissions to ambient air pollution and mortality in European cities: a health impact assessment.

BACKGROUND: Ambient air pollution is a major risk to health and wellbeing in European cities. We aimed to estimate spatial and sector-specific contributions of emissions to ambient air pollution and evaluate the effects of source-specific reductions in pollutants on mortality in European cities to support targeted source-specific actions to address air pollution and promote population health. METHODS: We conducted a health impact assessment of data from 2015 for 857 European cities to estimate source contributions to annual PM2·5 and NO2 concentrations using the Screening for High Emission Reduction Potentials for Air quality tool. We evaluated contributions from transport, industry, energy, residential, agriculture, shipping, and aviation, other, natural, and external sources. For each city and sector, three spatial levels were considered: contributions from the same city, the rest of the country, and transboundary. Mortality effects were estimated for adult populations (ie, ≥20 years) following standard comparative risk assessment methods to calculate the annual mortality preventable on spatial and sector-specific reductions in PM2·5 and NO2. FINDINGS: We observed strong variability in spatial and sectoral contributions among European cities. For PM2·5, the main contributors to mortality were the residential (mean contribution of 22·7% [SD 10·2]) and agricultural (18·0% [7·7]) sectors, followed by industry (13·8% [6·0]), transport (13·5% [5·8]), energy (10·0% [6·4]), and shipping (5·5% [5·7]). For NO2, the main contributor to mortality was transport (48·5% [SD 15·2]), with additional contributions from industry (15·0% [10·8]), energy (14·7% [12·9]), residential (10·3% [5·0]), and shipping (9·7% [12·7]). The mean city contribution to its own air pollution mortality was 13·5% (SD 9·9) for PM2·5 and 34·4% (19·6) for NO2, and contribution increased among cities of largest area (22·3% [12·2] for PM2·5 and 52·2% [19·4] for NO2) and among European capitals (29·9% [12·5] for PM2·5 and 62·7% [14·7] for NO2). INTERPRETATION: We estimated source-specific air pollution health effects at the city level. Our results show strong variability, emphasising the need for local policies and coordinated actions that consider city-level specificities in source contributions. FUNDING: Spanish Ministry of Science and Innovation, State Research Agency, Generalitat de Catalunya, Centro de Investigación Biomédica en red Epidemiología y Salud Pública, and Urban Burden of Disease Estimation for Policy Making 2023-2026 Horizon Europe project.

Impact of native-plants policy scenarios on premature mortality in Denver: A quantitative health impact assessment.

BACKGROUND: Cities often use non-native plants such as turf grass to expand green space. Native plants, however, may require less water and maintenance and have co-benefits for local biodiversity, including pollinators. Previous studies estimating mortality averted by adding green space have not considered the provision of native plants as part of the greening policies. AIM: We aim to estimate premature deaths that would be prevented by the implementation of native-plants policy scenarios in the City of Denver, Colorado, USA. METHODS: After conducting interviews with local expert stakeholders, we designed four native-plants policy scenarios: (1) greening 30% of all city census-block groups to the greenness level of native plants, (2) adding 200-foot native-plants buffers around riparian areas, (3) constructing large water retention ponds landscaped with native plants, and (4) greening parking lots. We defined the normalized difference vegetation index (NDVI) corresponding to native plants by measuring the NDVI at locations with known native or highly diverse vegetation. Using a quantitative health-impact assessment approach, we estimated premature mortality averted under each scenario, comparing alternative NDVI with the baseline value. RESULTS: In the most ambitious scenario, we estimated that 88 (95% uncertainty interval (UI): 20, 128) annual premature deaths would be prevented by greening 30% of the area of census block groups with native plants. We estimated that greening 30% of parking-lot surface with native plants would prevent 14 annual deaths (95% UI: 7, 18), adding the native buffers around riparian areas would prevent 13 annual deaths (95% UI: 2, 20), and adding the proposed stormwater retention ponds would prevent no annual deaths (95% UI: 0, 1). CONCLUSION: Using native plants to increase green spaces has the potential to prevent premature deaths in the City of Denver, but results were sensitive to the definition of native plants and the policy scenario.