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Blighted urban environments can be detrimental to community life and result in alienation and isolation. An intervention was developed in 2003 in Portland, Oregon, to engage low- to moderate-income, urban communities in creating pleasant amenities in the public right-of-way, including ecologically built information kiosks, benches, trellises for hanging gardens, and interactive art features such as large street paintings and art walls. As part of a postintervention survey of 359 residents within a two-block radius at three project sites, 53% rated their neighborhood better than before and 44% or 53% rated their present neighborhood as an excellent or good place to live, respectively. In open-ended qualitative comments, 30% mentioned increased social interactions, 13% revealed an enhanced sense of place, 43% described neighborhood participation, and 20% discussed aesthetic aspects of their local environment. Community involvement in urban design can enrich social networks with direct benefits for social capital and well-being.

Background: Three major international agreements signed in 2015 are key milestones for transitioning to more sustainable and resilient societies: the UN 2030 Agenda for Sustainable Development; the Sendai Framework for Disaster Risk Reduction; and the Paris Agreement under the United Nations Framework Convention on Climate Change. Together, these agreements underscore the critical importance of understanding and managing the health risks of global changes, to ensure continued population health improvements in the face of significant social and environmental change over this century. Body: Funding priorities of major health institutions and organizations in the U.S. and Europe do not match research investments with needs to inform implementation of these international agreements. In the U.S., the National Institutes of Health commit 0.025 % of their annual research budget to climate change and health. The European Union Seventh Framework Programme committed 0.08 % of the total budget to climate change and health; the amount committed under Horizon 2020 was 0.04 % of the budget. Two issues apparently contributing to this mismatch are viewing climate change primarily as an environmental problem, and therefore the responsibility of other research streams; and narrowly framing research into managing the health risks of climate variability and change from the perspective of medicine and traditional public health. This reductionist, top-down perspective focuses on proximate, individual level risk factors. While highly successful in reducing disease burdens, this framing is insufficient to protect health and well-being over a century that will be characterized by profound social and environmental changes. Conclusions: International commitments in 2015 underscored the significant challenges societies will face this century from climate change and other global changes. However, the low priority placed on understanding and managing the associated health risks by national and international research institutions and organizations leaves populations poorly prepared to cope with changing health burdens. Risk-centered, systems approaches can facilitate understanding of the complex interactions and dependencies across environmental, social, and human systems. This understanding is needed to formulate effective interventions targeting socio-environmental factors that are as important for determining health burdens as are individual risk factors.

BACKGROUND: Global climate change impacts on human and natural systems are predicted to be severe, far reaching, and to affect the most physically and economically vulnerable disproportionately. Society can respond to these threats through two strategies: mitigation and adaptation. Industry, commerce, and government play indispensable roles in these actions but so do individuals, if they are receptive to behavior change. We explored whether the health frame can be used as a context to motivate behavioral reductions of greenhouse gas emissions and adaptation measures. METHODS: In 2008, we conducted a cross-sectional survey in the United States using random digit dialing. Personal relevance of climate change from health threats was explored with the Health Belief Model (HBM) as a conceptual frame and analyzed through logistic regressions and path analysis. RESULTS: Of 771 individuals surveyed, 81% (n = 622) acknowledged that climate change was occurring, and were aware of the associated ecologic and human health risks. Respondents reported reduced energy consumption if they believed climate change could affect their way of life (perceived susceptibility), Odds Ratio (OR) = 2.4 (95% Confidence Interval (CI): 1.4-4.0), endanger their life (perceived severity), OR = 1.9 (95% CI: 1.1-3.1), or saw serious barriers to protecting themselves from climate change, OR = 2.1 (95% CI: 1.2-3.5). Perceived susceptibility had the strongest effect on reduced energy consumption, either directly or indirectly via perceived severity. Those that reported having the necessary information to prepare for climate change impacts were more likely to have an emergency kit OR = 2.1 (95% CI: 1.4-3.1) or plan, OR = 2.2 (95% CI: 1.5-3.2) for their household, but also saw serious barriers to protecting themselves from climate change or climate variability, either by having an emergency kit OR = 1.6 (95% CI: 1.1-2.4) or an emergency plan OR = 1.5 (95%CI: 1.0-2.2). CONCLUSIONS: Motivation for voluntary mitigation is mostly dependent on perceived susceptibility to threats and severity of climate change or climate variability impacts, whereas adaptation is largely dependent on the availability of information relevant to climate change. Thus, the climate change discourse could be framed from a health perspective to motivate behaviour change.

OBJECTIVES: Restricting mobility is a central aim for lowering contact rates and preventing COVID-19 transmission. Yet the impact on mobility of different non-pharmaceutical countermeasures in the earlier stages of the pandemic is not well-understood. DESIGN: Trends were evaluated using Citymapper's mobility index covering 2nd to 26th March 2020, expressed as percentages of typical usage periods from 0% as the lowest and 100% as normal. China and India were not covered. Multivariate fixed effects models were used to estimate the association of policies restricting movement on mobility before and after their introduction. Policy restrictions were assessed using the Oxford COVID-19 Government Response Stringency Index as well as measures coding the timing and degree of school and workplace closures, transport restrictions, and cancellation of mass gatherings. SETTING: 41 cities worldwide. MAIN OUTCOME MEASURES: Citymapper's mobility index. RESULTS: Mobility declined in all major cities throughout March. Larger declines were seen in European than Asian cities. The COVID-19 Government Response Stringency Index was strongly associated with declines in mobility (r = - 0.75, p < 0.001). After adjusting for time-trends, we observed that implementing non-pharmaceutical countermeasures was associated with a decline of mobility of 10.0% for school closures (95% CI: 4.36 to 15.7%), 15.0% for workplace closures (95% CI: 10.2 to 19.8%), 7.09% for cancelling public events (95% CI: 1.98 to 12.2%), 18.0% for closing public transport (95% CI: 6.74 to 29.2%), 13.3% for restricting internal movements (95% CI: 8.85 to 17.8%) and 5.30% for international travel controls (95% CI: 1.69 to 8.90). In contrast, as expected, there was no association between population mobility changes and fiscal or monetary measures or emergency healthcare investment. CONCLUSIONS: Understanding the effect of public policy on mobility in the early stages is crucial to slowing and reducing COVID-19 transmission. By using Citymapper's mobility index, this work provides the first evidence about trends in mobility and the impacts of different policy interventions, suggesting that closure of public transport, workplaces and schools are particularly impactful.

OBJECTIVES: Restricting mobility is a central aim for lowering contact rates and preventing COVID-19 transmission. Yet the impact on mobility of different non-pharmaceutical countermeasures in the earlier stages of the pandemic is not well-understood. DESIGN: Trends were evaluated using Citymapper's mobility index covering 2nd to 26th March 2020, expressed as percentages of typical usage periods from 0% as the lowest and 100% as normal. China and India were not covered. Multivariate fixed effects models were used to estimate the association of policies restricting movement on mobility before and after their introduction. Policy restrictions were assessed using the Oxford COVID-19 Government Response Stringency Index as well as measures coding the timing and degree of school and workplace closures, transport restrictions, and cancellation of mass gatherings. SETTING: 41 cities worldwide. MAIN OUTCOME MEASURES: Citymapper's mobility index. RESULTS: Mobility declined in all major cities throughout March. Larger declines were seen in European than Asian cities. The COVID-19 Government Response Stringency Index was strongly associated with declines in mobility (r = − 0.75, p < 0.001). After adjusting for time-trends, we observed that implementing non-pharmaceutical countermeasures was associated with a decline of mobility of 10.0% for school closures (95% CI: 4.36 to 15.7%), 15.0% for workplace closures (95% CI: 10.2 to 19.8%), 7.09% for cancelling public events (95% CI: 1.98 to 12.2%), 18.0% for closing public transport (95% CI: 6.74 to 29.2%), 13.3% for restricting internal movements (95% CI: 8.85 to 17.8%) and 5.30% for international travel controls (95% CI: 1.69 to 8.90). In contrast, as expected, there was no association between population mobility changes and fiscal or monetary measures or emergency healthcare investment. CONCLUSIONS: Understanding the effect of public policy on mobility in the early stages is crucial to slowing and reducing COVID-19 transmission. By using Citymapper's mobility index, this ...

Background: The COVID-19 pandemic and associated policy responses, such as physical distancing interventions, pose risks to mental health that could be mitigated by social support systems. We examine associations between changes in mental health in the population aged 50 years and older in Europe and stringency of pandemic responses and social protection. Methods: We analysed data from the Survey of Health, Ageing and Retirement in Europe: n = 50,278 individuals aged 50 years and older in 26 European countries between June and August 2020. Linear multivariable regression models were used to evaluate potential risk factors for deterioration in self-reported mental health and investigate whether social protection systems mitigate it. Results: Across the European Union, 28.1% (95% CI:27.1-29.2) of participants reported worsening mental health since the beginning of the pandemic, ranging from 16.1% in Slovakia to 54.8% in Portugal. Factors associated with increased risk of deterioration included: being female (12.7 percentage points (ppt), 95%CI:9.2-16.2); experiencing unmet healthcare needs during the pandemic (14.6 ppt, 95%CI:11.2-18.1); job loss during the pandemic (6.2 ppt, 95%CI:1.1-11.8); and financial hardship (5.1 ppt, 95%CI:2.9-7.2). Greater stringency of physical distancing measures in countries was associated with worsening mental health (0.2 ppt per each one point increase on a stringency index, 95% CI:0.09-0.4); however, country-level pre-pandemic expenditures on various social protection packages was associated with decreased probability of worsening mental health (-1.3 ppt, 95%CI: 0.3 to -2.3 per €1,000 increase in health care expenditures per capita and, among the unemployed, -3.8 ppt, 95%CI: 1.6 to -2.4 per €100 increase in unemployment expenditure per capita). Conclusions: The COVID-19 pandemic has been associated with substantial mental health deterioration exhibiting social inequalities. Adverse mental health has been exacerbated by policy responses to the pandemic regulating physical distancing, but social protection expenditure might have helped mitigate the impact. Strengthening social protection systems might render the mental health of the population more resilient to the consequences of crises such as the COVID-19 pandemic.

Background: Sex workers are disproportionately affected by HIV compared with the general population. Most studies of HIV risk among sex workers have focused on individual-level risk factors, with few studies assessing potential structural determinants of HIV risk. In this Article, we examine whether criminal laws around sex work are associated with HIV prevalence among female sex workers. Method: We estimate cross-sectional, ecological regression models with data from 27 European countries on HIV prevalence among sex workers from the European Centre for Disease Control; sex-work legislation from the US State Department's Country Reports on Human Rights Practices and country-specific legal documents; the rule of law and gross-domestic product per capita, adjusted for purchasing power, from the World Bank; and the prevalence of injecting drug use among sex workers. Although data from two countries include male sex workers, the numbers are so small that the findings here essentially pertain to prevalence in female sex workers. Findings: Countries that have legalised some aspects of sex work (n=17) have significantly lower HIV prevalence among sex workers than countries that criminalise all aspects of sex work (n=10; β=–2·09, 95% CI −0·80 to −3·37; p=0·003), even after controlling for the level of economic development (β=–1·86; p=0·038) and the proportion of sex workers who are injecting drug users (−1·93; p=0·026). We found that the relation between sex work policy and HIV among sex workers might be partly moderated by the effectiveness and fairness of enforcement, suggesting legalisation of some aspects of sex work could reduce HIV among sex workers to the greatest extent in countries where enforcement is fair and effective. Interpretation: Our findings suggest that the legalisation of some aspects of sex work might help reduce HIV prevalence in this high-risk group, particularly in countries where the judiciary is effective and fair.

OBJECTIVE: To investigate whether the economic recession affected the control of tuberculosis in the European Union. METHODS: Multivariate regression models were used to quantify the association between gross domestic product, public health expenditure and tuberculosis case detection rates, using data from 21 European Union member states (1991-2012). The estimated changes in case detection attributable to the recession were combined with mathematical models of tuberculosis transmission, to project the potential influence of the recession on tuberculosis epidemiology until 2030. FINDINGS: Between 1991 and 2007, detection rates for sputum-smear-positive tuberculosis in the European Union were stable at approximately 85%. During the economic recession (2008-2011) detection rates declined by a mean of 5.22% (95% confidence interval, CI: 2.54-7.90) but treatment success rates showed no significant change (P = 0.62). A fall in economic output of 100 United States dollars per capita was associated with a 0.22% (95% CI: 0.05-0.39) mean reduction in the tuberculosis case detection rate. An equivalent fall in spending on public health services was associated with a 2.74% (95% CI: 0.31-5.16) mean reduction in the detection rate. Mathematical models suggest that the recession and consequent austerity policies will lead to increases in tuberculosis prevalence and tuberculosis-attributable mortality that are projected to persist for over a decade. CONCLUSION: Across the European Union, reductions in spending on public health services appear to have reduced tuberculosis case detection and to have increased the long-term risk of a resurgence in the disease.

BACKGROUND: Sex workers are disproportionately affected by HIV compared with the general population. Most studies of HIV risk among sex workers have focused on individual-level risk factors, with few studies assessing potential structural determinants of HIV risk. In this Article, we examine whether criminal laws around sex work are associated with HIV prevalence among female sex workers. METHOD: We estimate cross-sectional, ecological regression models with data from 27 European countries on HIV prevalence among sex workers from the European Centre for Disease Control; sex-work legislation from the US State Department's Country Reports on Human Rights Practices and country-specific legal documents; the rule of law and gross-domestic product per capita, adjusted for purchasing power, from the World Bank; and the prevalence of injecting drug use among sex workers. Although data from two countries include male sex workers, the numbers are so small that the findings here essentially pertain to prevalence in female sex workers. FINDINGS: Countries that have legalised some aspects of sex work (n=17) have significantly lower HIV prevalence among sex workers than countries that criminalise all aspects of sex work (n=10; β=-2·09, 95% CI -0·80 to -3·37; p=0·003), even after controlling for the level of economic development (β=-1·86; p=0·038) and the proportion of sex workers who are injecting drug users (-1·93; p=0·026). We found that the relation between sex work policy and HIV among sex workers might be partly moderated by the effectiveness and fairness of enforcement, suggesting legalisation of some aspects of sex work could reduce HIV among sex workers to the greatest extent in countries where enforcement is fair and effective. INTERPRETATION: Our findings suggest that the legalisation of some aspects of sex work might help reduce HIV prevalence in this high-risk group, particularly in countries where the judiciary is effective and fair. FUNDING: European Centre for Disease Prevention and Control.

Recurrent health emergencies threaten global health security. International Health Regulations (IHR) aim to prevent, detect and respond to such threats, through increase in national public health core capacities, but whether IHR core capacity implementation is necessary and sufficient has been contested. With a longitudinal study we relate changes in national IHR core capacities to changes in cross‐border infectious disease threat events (IDTE) between 2010 and 2016, collected through epidemic intelligence at the European Centre for Disease Prevention and Control (ECDC). By combining all IHR core capacities into one composite measure we found that a 10% increase in the mean of this composite IHR core capacity to be associated with a 19% decrease (p = 0.017) in the incidence of cross‐border IDTE in the EU. With respect to specific IHR core capacities, an individual increase in national legislation, policy & financing; coordination and communication with relevant sectors; surveillance; response; preparedness; risk communication; human resource capacity; or laboratory capacity was associated with a significant decrease in cross‐border IDTE incidence. In contrast, our analysis showed that IHR core capacities relating to point‐of‐entry, zoonotic events or food safety were not associated with IDTE in the EU. Due to high internal correlations between core capacities, we conducted a principal component analysis which confirmed a 20% decrease in risk of IDTE for every 10% increase in the core capacity score (95% CI: 0.73, 0.88). Globally (EU excluded), a 10% increase in the mean of all IHR core capacities combined was associated with a 14% decrease (p = 0.077) in cross‐border IDTE incidence. We provide quantitative evidence that improvements in IHR core capacities at country‐level are associated with fewer cross‐border IDTE in the EU, which may also hold true for other parts of the world.

Recurrent health emergencies threaten global health security. International Health Regulations (IHR) aim to prevent, detect and respond to such threats, through increase in national public health core capacities, but whether IHR core capacity implementation is necessary and sufficient has been contested. With a longitudinal study we relate changes in national IHR core capacities to changes in cross‐border infectious disease threat events (IDTE) between 2010 and 2016, collected through epidemic intelligence at the European Centre for Disease Prevention and Control (ECDC). By combining all IHR core capacities into one composite measure we found that a 10% increase in the mean of this composite IHR core capacity to be associated with a 19% decrease (p=0.017) in the incidence of cross‐border IDTE in the EU. With respect to specific IHR core capacities, an individual increase in national legislation, policy & financing; coordination and communication with relevant sectors; surveillance; response; preparedness; risk communication; human resource capacity; or laboratory capacity was associated with a significant decrease in cross‐border IDTE incidence. In contrast, our analysis showed that IHR core capacities relating to point‐of‐entry, zoonotic events or food safety were not associated with IDTE in the EU. Due to high internal correlations between core capacities, we conducted a principal component analysis which confirmed a 20% decrease in risk of IDTE for every 10% increase in the core capacity score (95% CI: 0.73, 0.88). Globally (EU excluded), a 10% increase in the mean of all IHR core capacities combined was associated with a 14% decrease (p=0.077) in cross‐border IDTE incidence. We provide quantitative evidence that improvements in IHR core capacities at country‐level are associated with fewer cross‐border IDTE in the EU, which may also hold true for other parts of the world.