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BACKGROUND: Increasing urban bicycling has established net benefits for human and environmental health. Questions remain about which policies are needed and in what order, to achieve an increase in cycling while avoiding negative consequences. Novel ways of considering cycling policy are needed, bringing together expertise across policy, community and research to develop a shared understanding of the dynamically complex cycling system. In this paper we use a collaborative learning process to develop a dynamic causal model of urban cycling to develop consensus about the nature and order of policies needed in different cycling contexts to optimise outcomes. METHODS: We used participatory system dynamics modelling to develop causal loop diagrams (CLDs) of cycling in three contrasting contexts: Auckland, London and Nijmegen. We combined qualitative interviews and workshops to develop the CLDs. We used the three CLDs to compare and contrast influences on cycling at different points on a "cycling trajectory" and drew out policy insights. RESULTS: The three CLDs consisted of feedback loops dynamically influencing cycling, with significant overlap between the three diagrams. Common reinforcing patterns emerged: growing numbers of people cycling lifts political will to improve the environment; cycling safety in numbers drives further growth; and more cycling can lead to normalisation across the population. By contrast, limits to growth varied as cycling increases. In Auckland and London, real and perceived danger was considered the main limit, with added barriers to normalisation in London. Cycling congestion and "market saturation" were important in the Netherlands. CONCLUSIONS: A generalisable, dynamic causal theory for urban cycling enables a more ordered set of policy recommendations for different cities on a cycling trajectory. Participation meant the collective knowledge of cycling stakeholders was represented and triangulated with research evidence. Extending this research to further cities, especially in low-middle income countries, would enhance generalizability of the CLDs. ; This research was funded by an MRC Centenary grant. JW's contribution was supported by an MRC Population Health Scientist Fellowship (MR/K021796/1). The work occurred under the auspices of the Centre for Diet and Activity Research (CEDAR), a UKCRC Public Health Research Centre of Excellence funded by the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research (NIHR), and the Wellcome Trust (MR/K023187/1).

BACKGROUND: Planners and politicians in many countries seek to increase the proportion of trips made by cycling. However, this is often challenging. In England, a national target to double cycling by 2025 is likely to be missed: between 2001 and 2011 the proportion of commutes made by cycling barely grew. One important contributory factor is continued low investment in cycling infrastructure, by comparison to European leaders. METHODS: This paper examines barriers to cycling investment, considering that these need to be better understood to understand failures to increase cycling level. It is based on qualitative data from an online survey of over 400 stakeholders, alongside seven in-depth interviews. RESULTS: Many respondents reported that change continues to be blocked by chronic barriers including a lack of funding and leadership. Participants provided insights into how challenges develop along the life of a scheme. In authorities with little consideration given to cycling provision, media and public opposition were not reported as a major issue. However, where planning and implementation have begun, this can change quickly; although examples were given of schemes successfully proceeding, despite this. The research points to a growing gap between authorities that have overcome key challenges, and those that have not.

BACKGROUND: Planners and politicians in many countries seek to increase the proportion of trips made by cycling. However, this is often challenging. In England, a national target to double cycling by 2025 is likely to be missed: between 2001 and 2011 the proportion of commutes made by cycling barely grew. One important contributory factor is continued low investment in cycling infrastructure, by comparison to European leaders. METHODS: This paper examines barriers to cycling investment, considering that these need to be better understood to understand failures to increase cycling level. It is based on qualitative data from an online survey of over 400 stakeholders, alongside seven in-depth interviews. RESULTS: Many respondents reported that change continues to be blocked by chronic barriers including a lack of funding and leadership. Participants provided insights into how challenges develop along the life of a scheme. In authorities with little consideration given to cycling provision, media and public opposition were not reported as a major issue. However, where planning and implementation have begun, this can change quickly; although examples were given of schemes successfully proceeding, despite this. The research points to a growing gap between authorities that have overcome key challenges, and those that have not.

Abstract

Introduction: The mass rapid transit (MRT) is the largest transport infrastructure project under the national key economic area (NKEA) in Malaysia. As urban rail is anticipated to be the future spine of public transport network in the Greater Kuala Lumpur city, it is important to mainstream climate change mitigation and public health benefits in the local transport development. This study quantifies the health co-benefits in terms of mortality among the urbanites when the first line of the 150 km MRT system in Kuala Lumpur commences by 2017.

Method: Using comparative health risk assessment, we estimated the potential health co-benefits from the establishment of the MRT system. We estimated the reduced CO2 emissions and air pollution (PM2.5) exposure reduction among the general population from the reduced use of motorized vehicles. Mortality avoided from traffic incidents involving motorcycles and passenger cars, and from increased physical activity from walking while using the MRT system was also estimated.

Results: A total of 363,130 tonnes of CO2 emissions could be reduced annually from the modal shift from cars and motorcycles to the MRT system. Atmospheric PM2.5 concentration could be reduced 0.61 μg/m3 annually (2%). This could avoid a total of 12 deaths, mostly from cardio-respiratory diseases among the city residents. For traffic injuries, 37 deaths could be avoided annually from motorcycle and passenger cars accidents especially among the younger age categories (aged 15–30). One additional death was attributed to pedestrian walking. The additional daily physical activity to access the MRT system could avoid 21 deaths among its riders. Most of the mortality avoided comes from cardiovascular diseases. Overall, a total of 70 deaths could be avoided annually among both the general population and the MRT users in the city.

Conclusion: The implementation of the MRT system in Greater Kuala Lumpur could bring substantial health co-benefits to both the general population and the MRT users mainly from the avoidance of mortality from traffic injuries.

Getting people cycling is an increasingly common objective in transport planning institutions worldwide. A growing evidence base indicates that high quality infrastructure can boost local cycling rates. Yet for infrastructure and other cycling measures to be effective, it is important to intervene in the right places, such as along 'desire lines' of high latent demand. This creates the need for tools and methods to help answer the question 'where to build?'. Following a brief review of the policy and research context related to this question, this paper describes the design, features and potential applications of such a tool. The Propensity to Cycle Tool (PCT) is an online, interactive planning support system that was initially developed to explore and map cycling potential across England (see www.pct.bike). Based on origin-destination data it models cycling levels at area, desire line, route and route network levels, for current levels of cycling, and for scenario-based 'cycling futures.' Four scenarios are presented, including 'Go Dutch' and 'Ebikes,' which explore what would happen if English people had the same propensity to cycle as Dutch people and the potential impact of electric cycles on cycling uptake. The cost effectiveness of investment depends not only on the number of additional trips cycled, but on wider impacts such as health and carbon benefits. The PCT reports these at area, desire line, and route level for each scenario. The PCT is open source, facilitating the creation of scenarios and deployment in new contexts. We conclude that the PCT illustrates the potential of online tools to inform transport decisions and raises the wider issue of how models should be used in transport planning.

BACKGROUND: Diabetes is highly prevalent in the Caribbean, associated with a high morbidity and mortality and is a recognised threat to economic and social development. Heads of Government in the Caribbean Community came together in 2007 and declared their commitment to reducing the burden of non-communicable diseases (NCDs), including diabetes, by calling for a multi-sectoral, systemic response. To facilitate the development of effective policies, policymakers are being engaged in the development and use of a system dynamics (SD) model of diabetes for Caribbean countries. METHODS: Previous work on a diabetes SD model from the United States of America (USA) is being adapted to a local context for three countries in the region using input from stakeholders, a review of existing qualitative and quantitative data, and collection of new qualitative data. Three country models will be developed using one-on-one stakeholder engagement and iterative revision. An inter-country model will also be developed following a model-building workshop. Models will be compared to each other and to the USA model. The inter-country model will be used to simulate policies identified as priorities by stakeholders and to develop targets for prevention and control. The model and model-building process will be evaluated by stakeholders and a manual developed for use in other high-burden developing regions. DISCUSSION: SD has been applied with success for health policy development in high-income country settings. The utility of SD in developing countries as an aid to policy decision-making related to NCDs has not been tested. This study represents the first of its kind. ; The project is funded by a health initiatives development grant sponsored by the DFID/MRC/Wellcome Trust/ESRC. Reference: MR/N005384/1.

The absence of reliable access to clean energy and the services it provides imposes a large disease burden on low-income populations and impedes prospects for development. Furthermore, current patterns of fossil-fuel use cause substantial ill-health from

The absence of reliable access to clean energy and the services it provides imposes a large disease burden on low-income populations and impedes prospects for development. Furthermore, current patterns of fossil-fuel use cause substantial ill-health from

Active travel (cycling, walking) is beneficial for the health due to increased physical activity (PA). However, active travel may increase the intake of air pollution, leading to negative health consequences. We examined the risk-benefit balance between active travel related PA and exposure to air pollution across a range of air pollution and PA scenarios. The health effects of active travel and air pollution were estimated through changes in all-cause mortality for different levels of active travel and air pollution. Air pollution exposure was estimated through changes in background concentrations of fine particulate matter (PM2.5), ranging from 5 to 200μg/m3. For active travel exposure, we estimated cycling and walking from 0 up to 16h per day, respectively. These refer to long-term average levels of active travel and PM2.5 exposure. For the global average urban background PM2.5 concentration (22μg/m3) benefits of PA by far outweigh risks from air pollution even under the most extreme levels of active travel. In areas with PM2.5 concentrations of 100μg/m3, harms would exceed benefits after 1h 30min of cycling per day or more than 10h of walking per day. If the counterfactual was driving, rather than staying at home, the benefits of PA would exceed harms from air pollution up to 3h 30min of cycling per day. The results were sensitive to dose-response function (DRF) assumptions for PM2.5 and PA. PA benefits of active travel outweighed the harm caused by air pollution in all but the most extreme air pollution concentrations. ; MT and JW: The work was undertaken by the Centre for Diet and Activity Research (CEDAR), a UKCRC Public Health Research Centre of Excellence. Funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research, and the Wellcome Trust, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged. AJN, DRR, MJN, SK and TG: The work was supported by the project Physical Activity through Sustainable Transportation Approaches (PASTA) funded by the European Union's Seventh Framework Program under EC‐GA No. 602624-2 (FP7-HEALTH-2013-INNOVATION-1). The sponsors had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. JW is supported by MRC Population Health Scientist fellowship. THS is supported by the Brazilian Science without Borders Scheme (Process number: 200358/2014-6) and the Sao Paulo Research Foundation (Process number: 2012/08565-4). ; This is the final version of the article. It first appeared from Elsevier via http://dx.doi.org/10.1016/j.ypmed.2016.02.002

Using a health impact assessment framework, we estimated the population health effects arising from alternative land-use and transport policy initiatives in six cities. Land-use changes were modelled to reflect a compact city in which land-use density and diversity were increased and distances to public transport were reduced to produce low motorised mobility, namely a modal shift from private motor vehicles to walking, cycling, and public transport. The modelled compact city scenario resulted in health gains for all cities (for diabetes, cardiovascular disease, and respiratory disease) with overall health gains of 420-826 disability-adjusted life-years (DALYs) per 100 000 population. However, for moderate to highly motorised cities, such as Melbourne, London, and Boston, the compact city scenario predicted a small increase in road trauma for cyclists and pedestrians (health loss of between 34 and 41 DALYs per 100 000 population). The findings suggest that government policies need to actively pursue land-use elements-particularly a focus towards compact cities-that support a modal shift away from private motor vehicles towards walking, cycling, and low-emission public transport. At the same time, these policies need to ensure the provision of safe walking and cycling infrastructure. The findings highlight the opportunities for policy makers to positively influence the overall health of city populations.

BACKGROUND: Road traffic is the main source of environmental noise in European cities and one of the main environmental risks to health and wellbeing. In this study we aimed to provide an in-depth assessment of available road traffic noise data and to estimate population exposure and health impacts for cities in Europe. METHODS: We conducted the analysis for 724 cities and 25 greater cities in 25 European countries. We retrieved road traffic strategic noise maps delivered under the Environmental Noise Directive (END) or available from local sources. We assessed noise exposure using the 24 h day-evening-night noise level indicator (Lden) starting at exposure levels of 55 dB Lden - based on data availability - for the adult population aged 20 and over (n = 123,966,346). For the adults exposed to noise levels above 55 dB Lden we estimated the health impacts of compliance with the World Health Organization (WHO) recommendation of 53 dB Lden. Two primary health outcomes were assessed: high noise annoyance and Ischemic Heart Disease (IHD), using mortality from IHD causes as indicator. Exposure Response Functions (ERFs) relating road traffic noise exposure to annoyance and IHD mortality were retrieved from the literature. Uncertainties in input parameters were propagated using Monte Carlo simulations to obtain point estimates and empirical 95% Confidence Intervals (CIs). Lastly, the noise maps were categorized as high, moderate and low quality following a qualitative approach. RESULTS: Strategic noise map data was delivered in three distinct formats (i.e. raster, polygon or polyline) and had distinct noise ranges and levels of categorization. The majority of noise maps (i.e. 83.2%) were considered of moderate or low quality. Based on the data provided, almost 60 million adults were exposed to road traffic noise levels above 55 dB Lden, equating to a median of 42% (Interquartile Range (IQR): 31.8-64.8) of the adult population across the analysed cities. We estimated that approximately 11 million adults were highly annoyed by road traffic noise and that 3608 deaths from IHD (95% CI: 843-6266) could be prevented annually with compliance of the WHO recommendation. The proportion of highly annoyed adults by city had a median value of 7.6% (IQR: 5.6-11.8) across the analysed cities, while the number preventable deaths had a median of 2.2 deaths per 100,000 population (IQR: 1.4-3.1). CONCLUSIONS: Based on the provided strategic noise maps a considerable number of adults in European cities are exposed to road traffic noise levels harmful for health. Efforts to standardize the strategic noise maps and to increase noise and disease data availability at the city level are needed. These would allow for a more accurate and comprehensive assessment of the health impacts and further help local governments to address the adverse health effects of road traffic noise.

Introduction: Reductions in traffic speed can potentially offer multiple health and public health benefits. In 2016, implementation of 20mph (30kph) speed limit interventions began in Edinburgh (city-wide) and Belfast (city centre). The aims of this paper are to describe 1) the broad theoretical approach and design of two natural experimental studies to evaluate the 20mph speed limits in Edinburgh and Belfast and 2) how these studies allowed us to test and explore theoretical mechanisms of 20mph speed limit interventions. Methods: The evaluation consisted of several work packages, each with different research foci, including the political decision-making processes that led to the schemes, their implementation processes, outcomes (including traffic speed, perceptions of safety, and casualties) and cost effectiveness. We used a combination of routinely and locally collected quantitative data and primary quantitative and qualitative data. Results: The evaluation identified many contextual factors influencing the likelihood of 20mph speed limits reaching the political agenda. There were substantial differences between the two sites in several aspects related to implementation. Reductions in speed resulted in significant reductions in collisions and casualties, particularly in Edinburgh, which had higher average speed at baseline. The monetary value of collisions and casualties prevented are likely to exceed the costs of the intervention and thus the overall balance of costs and benefits is likely to be favourable. Conclusions: Innovative study designs, including natural experiments, are important for assessing the impact of 'real world' public health interventions. Using multiple methods, this project enabled a deeper understanding of not only the effects of the intervention but the factors that explain how and why the intervention and the effects did or did not occur. Importantly it has shown that 20mph speed limits can lead to reductions in speed, collisions and casualties, and are therefore an effective public health intervention.