A cross-sectional analysis among 1041 urban residents was done to examine associations between self-reported walking distance to and use of freshwater urban blue space and health-related quality of life in two German cities: a city with "poor" urban blue space supply (Bielefeld; 0.8% blue space) and one with "better" urban blue space supply (Gelsenkirchen; 3.0% blue space). Health-related quality of life was assessed with the SF-12v2, which measures residents' self-reported mental and physical health. Results showed a significant association between use frequency and perceived walking distance to blue space. Blue space use was a better indicator of health outcomes than perceived walking distance. After controlling for green space, socio-economic and demographic variables, use frequency was associated with higher mental health in Gelsenkirchen. These cross-sectional findings suggest that blue space use increases the probability of being healthier in highly urbanised areas in cities with an appropriate amount of blue space.

A multidisciplinary research project series has sought to identify and better understand multiple hygienic–microbiological and chemical contaminations from both point sources and diffuse pollution to contribute to the improvement in surface water quality. In the catchment area of the river Swist (Germany), municipal sewage treatment plants were investigated, followed by event-based investigation of combined sewer overflows, rainwater retention basins and diffuse pollution by surface and subsurface run-off as well as drain pipes. Recently, retention soil filters installed between stormwater storage basins and receiving surface waters in order to provide further treatment of combined sewer overflows were investigated. Geographical information system analysis helped to examine the data in their temporal and spatial dimensions. A model for calculating microbial and chemical loads within a catchment area was developed (“Swistbox”) which provides an efficient tool for risk assessment. Nearly two decades of investigation has demonstrated that several elements of the landscape’s water balance account for surface water pollution from both diffuse and point sources. Depending on land cover characteristics, wastewater technology and the proportion of wastewater as compared to total river water flow, a source can vary in its importance for the catchment area. The findings can be applied for sustainable and health-sensitive catchment management in relation to recreational or agricultural water use as well as ecological aspects.

Blue space can be regarded as a key component of urban development as it contributes to sustainability, landscape contextualisation, environmental quality, quality of life and human health. However, existing studies on urban blue spaces do not differentiate between size and type of space and do not explain the mechanisms of how urban blue spaces interact with appropriations that affect health. In our study, we chose seven urban open spaces in Germany with different types of urban blue (in the cities of Bielefeld, Gelsenkirchen, Dusseldorf, Cologne). We conducted standardised qualitative interviews with n = 211 urban blue space visitors, assessing their health-related appropriations of those spaces (use, experience, social, meaning). Via Correspondence Analysis, we profiled these seven spaces. Our results show that blue experience is an important appropriation in urban open spaces. The amount of green and blue space has a significant influence on health-related appropriative processes. Health-related appropriations shift with the profile of the blue urban open space and the proportion of land the blue space covers. Even in cities with few water features, urban blue induces intensive (restorative) experiences, creates meaning, attracts urban dwellers, promotes physical activity, and diversifies health experiences in urban contexts. We identify implications for public health, urban planning and landscape design. This paper is a valuable contribution to the current research trend in Germany to analyse the significance for human health and well-being of bodies of water in urban areas.

BACKGROUND:The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. METHODS:Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. FINDINGS:All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. INTERPRETATION:Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks. FUNDING:Bill & Melinda Gates Foundation.

Background: Environmental health effects vary considerably with regard to their severity, type of disease, and duration. Integrated measures of population health, such as environmental burden of disease (EBD), are useful for setting priorities in environmental health policies and research. This review is a summary of the full Environmental Burden of Disease in European countries (EBoDE) project report. Objectives: The EBoDE project was set up to provide assessments for nine environmental risk factors relevant in selected European countries (Belgium, Finland, France, Germany, Italy, and the Netherlands). Methods: Disability-adjusted life years (DALYs) were estimated for benzene, dioxins, secondhand smoke, formaldehyde, lead, traffic noise, ozone, particulate matter (PM2.5), and radon, using primarily World Health Organization data on burden of disease, (inter)national exposure data, and epidemiological or toxicological risk estimates. Results are presented here without discounting or age-weighting. Results: About 3–7% of the annual burden of disease in the participating countries is associated with the included environmental risk factors. Airborne particulate matter (diameter ≤ 2.5 μm; PM2.5) is the leading risk factor associated with 6,000–10,000 DALYs/year and 1 million people. Secondhand smoke, traffic noise (including road, rail, and air traffic noise), and radon had overlapping estimate ranges (600–1,200 DALYs/million people). Some of the EBD estimates, especially for dioxins and formaldehyde, contain substantial uncertainties that could be only partly quantified. However, overall ranking of the estimates seems relatively robust. Conclusions: With current methods and data, environmental burden of disease estimates support meaningful policy evaluation and resource allocation, including identification of susceptible groups and targets for efficient exposure reduction. International exposure monitoring standards would enhance data quality and improve comparability. Citation: Hänninen O, Knol AB, Jantunen M, Lim TA, Conrad A, Rappolder M, Carrer P, Fanetti AC, Kim R, Buekers J, Torfs R, Iavarone I, Classen T, Hornberg C, Mekel OC, EBoDE Working Group. 2014. Environmental burden of disease in Europe: assessing nine risk factors in six countries. Environ Health Perspect 122:439–446; http://dx.doi.org/10.1289/ehp.1206154

OBJECTIVE:Demographic changes in Germany are expected to cause a rising need for medical care and therapy while capacities are declining. Telemedicine offers the option of minimizing some aspects of these problems, but so far, many telemedicine projects in Germany (including telemonitoring projects) are not applied to the clinical routine. This study was done to assess the influence of health factors on potential willingness to use telemonitoring devices at home.MATERIALS AND METHODS:Health status and other health-relevant factors were determined using individual and medical factors (e.g., reported diseases). Principal-component analysis was used to identify groups with a specific response behavior. This study was based on a representative telephone survey conducted in the German state of North Rhine-Westphalia in 2009.RESULTS:Willingness to use telemonitoring was high in North Rhine-Westphalia but decreased with age. Men showed a significantly greater willingness to use telemonitoring than did women. Also, there was an effect associated with the subjects' health status (e.g., cardiovascular diseases caused a decrease of 9.7% in the level of acceptance, whereas musculoskeletal disorders caused a decrease of 5.1%).CONCLUSIONS:The target groups for telemonitoring consisted mainly of elderly persons and those with certain diseases. This study showed that being diseased lowered the willingness to use telemonitoring. People need to understand better how telemonitoring can help to improve controlling their health status and coping with the disease. It is necessary to reflect on these specific needs if telemonitoring is to become routine in the German healthcare system.

BackgroundThe German VegAS project (long title: Distribution-based analysis of the health effect of environmental stressors) deals with the health impact of environmental stressors in Germany, aiming for a comparative risk assessment (CRA) using the environmental burden-of-disease (EBD) approach developed by WHO.MethodsExtensive literature and data searches were conducted to determine the evidence-based environment–health relations of seven stressors (benzene, cadmium, noise [various types], ozone, particulate matter, perfluorinated compounds [PFC], and second-hand smoke) and their distribution of exposure in Germany. The EBD was expressed as lost disability-adjusted life-years (DALYs) attributable to these stressors. Uncertainties and limitations at different stages of the analysis were identified and discussed in detail. Moreover, an expert meeting was held to review the methods and data. The VegAS results were discussed regarding compatibility requirements of CRA.FindingsDALYs attributable to the seven environmental stressors were determined for 11 health outcomes, some of them attributed to more than one stressor. Five stressors could be associated with years of life lost. The quality of EBD quantification was restricted by missing sources of exposure data, lack of exposure–response functions, or incomplete knowledge on the outcome weighting. DALY estimates were reported for all stressors except PFC.InterpretationA full DALY calculation failed for several outcomes because of insufficient or missing data. CRAs building on this approach should therefore be interpreted with caution. The VegAS results provide evidence-based, stressor-specific EBD estimates that can support informed decision making in environmental health. These estimates, however, should be used against the background of a detailed uncertainty analysis that should also help close data gaps, as applied in VegAS.FundingThe VegAS project was funded by the Federal Ministry of Environment, Nature Conservation, and Nuclear Safety in context of the Environment Research Plan 2009. The corresponding author had full access to all the data in the study and final responsibility for the decision to submit for publication.

The objective of the present pilot study was the examination of self-reported health of seafarers and their attitudes towards health promotion. Against the background that seafarers are a target group which is difficult to reach, the methodological approach to ask the seafarers directly during their landbased residence was tested. From June to July 2009 a survey of a total of 49 seafarers was performed.In the results of the pilot study it was shown that the self-reported health of seafarers was undistinguished. Nobody reported to suffer from constant pain. Participation and compliance in the study was very good with a response rate of 71 %. Therefore, despite methodological challenges a direct survey of seafarers is recommended.

Die vorliegende Pilotstudie untersuchte die Gesundheit von Seeleuten sowie ihre Einstellung zur Gesundheitsförderung. Vor dem Hintergrund, dass Seeleute eine schwer zu erreichende Zielgruppe sind, wurde getestet, inwieweit eine direkte Befragung bei deren Landgang zielführend ist. Von Juni bis Juli 2009 konnte eine schriftliche Befragung bei insgesamt 49 Seeleuten realisiert werden. Insgesamt zeigte sich in den Ergebnissen der Pilotstudie, dass der selbst berichtete Gesundheitszustand der befragten Seeleute mittelmäßig ist. Keiner litt jedoch nach eigenen Angaben unter ständigen Beschwerden. Die Bereitschaft zur Teilnahme war mit 71 % ausgesprochen gut. Daher ist trotz methodischer Herausforderungen eine direkte Befragung der Seeleute zu empfehlen.

BackgroundCadmium is associated with several human health effects. Exposure via ambient background air is far less significant than through the food chain. The question is whether current concentrations of cadmium in the air still pose a health threat in terms of attributable cases of lung cancer in Germany. The German VegAS project (long title: Distribution-based analysis of the health effect of environmental stressors) quantified the environmental burden of disease (EBD) of cadmium in ambient air.MethodsA comprehensive review of the literature until early 2012 was done to identify cadmium-induced health outcomes and exposure–response functions. Evidence was checked using predefined criteria. National data sources for health and exposure information were consulted to estimate disability-adjusted life-years (DALYs) lost due to cadmium. The range of uncertainty by variation of uncertain parameters was described in detail.FindingsDALYs of lung cancer due to inhalation of cadmium in ambient background air in Germany (0·2131 ng/m3) were quantifiable and estimated at 7 DALYs lost (0·0087 DALYs per 100 000 population). Uncertainty analysis using various unit risk estimates yielded a maximum of 348 DALYs.InterpretationBy quantifying the EBD of airborne cadmium and lung cancer, only a very small part of the total EBD due to cadmium is quantified. Still, looking only at this small fraction of possible EBD due to cadmium, up to 348 DALYs (range maximum) could be prevented if this toxic substance was reduced to zero. Evidence supports an association between exposure to cadmium and kidney damage; bone disease; and lung, kidney, and prostate cancer. However, incompatibility of data affecting all dimensions of exposure and the EBD model undercut most quantification for supporting a scientifically validated environmental health policy.FundingThe VegAS project was funded by the Federal Ministry of Environment, Nature Conservation, and Nuclear Safety in context of the Environment Research Plan 2009. The corresponding author had full access to all the data in the study and final responsibility for the decision to submit for publication.

BackgroundDespite extensive regulations, the carcinogen benzene remains of high environmental and public health relevance. Benzene in ambient air is regulated by European Union (EU) directive 2008/50/EC (5 μg/m3). The current mean annual concentration in Germany meets the requirements, maintaining a value below the limit. The VegAS project (long title: Distribution-based analysis of the health effect of environmental stressors) estimated the burden of leukaemia due to benzene as well as health gains achieved by maintaining a lower benzene concentration than directed by the EU limit.MethodsThe environmental burden of disease approach was used to quantify disability-adjusted life-years (DALYs) of leukaemia attributable to the current benzene concentrations in indoors and ambient air in Germany. Evidence-based exposure–response relations were considered and we consulted national data sources for health and exposure information. We conducted uncertainty analyses for a range of uncertain parameters. A "what if" analysis using a hypothetical concentration of 5μg/m3 of benzene was used to estimate the health gains made from maintaining a mean benzene exposure lower than the EU limit.FindingsFrom the total 103 322 DALYs presently lost due to leukaemia in Germany, an estimated 181 DALYs (0·22 DALYs per 100 000 population) are attributable to airborne benzene at a mean background exposure concentration of 1·83 μg/m3. Varying alternative exposure–response relations yielded the widest range of uncertainty (2–341 DALYs). Assuming a benzene concentration of 5μg/m3 in indoor and ambient air yielded 484 DALYs. Consequently, health gains of 303 DALYs are expected to be attributable to maintaining a mean level significantly lower than 5μg/m3.InterpretationThis analysis focused on a public health view of background benzene exposure. Keeping the current benzene concentration on average below 5μg/m3 lowered the leukaemia burden from benzene by nearly a third. This analysis did not consider peak exposures (eg, traffic) and the potentially higher risks of individuals (eg, smokers). Health gain analyses are vital for stimulating health-related environmental protection.FundingThe VegAS project was funded by the Federal Ministry of Environment, Nature Conservation, and Nuclear Safety in the context of the Environment Research Plan 2009. The corresponding author had full access to all the data in the study and final responsibility for the decision to submit for publication.

city. The meta-analysis suggested that a cooling effect of 2.5 K (CI 95% 1.9-3.2 K, p<0.01) during the warmest months on northern hemisphere (between May and October) can be attributed to urban blue sites when including remote sensing data. However, research on the air temperature effects of urban blue space remains sparse compared to studies on urban green. The cooling effects clearly attributable to urban blue space are limited by surrounding environmental conditions like microclimate, urban development, wind velocity, wind turbulence, wind direction, temperature and humidity. Future research is needed to help planners use urban blue space efficiently as a temperature-mitigating and health protecting and promoting factor. The temperature-mitigating capacity of urban blue can potentially reduce heat stress in urban areas. To create healthy environments in the cities of the future, a better understanding of health affecting aspects of urban blue is needed to initiate public health action. Zusammenfassung: Der Klimawandel wird bereits heute als eine der grosten zukunftigen Herausforderungen fur Stadte angesehen. Um resultierende Temperaturerhohungen und die damit verbundenen Risiken fur die offentliche Ge sundheit abzumildern, fokussieren viele Handlungsempfehlungen auf die zunehmende Integration stadtgruner Raume. Stadtblaue Raume, definiert als alle Oberflachengewasser innerhalb einer Stadt, sind als moglicher Faktor fur eine Tem peraturabmilderung bereits anerkannt. Ihre Wirkungen wurden bislang jedoch nicht in ausreichendem Mase quantifiziert und verbleiben daher in der aktuellen Forschung und Planungspraxis sowie Handlungsempfehlungen unterreprasentiert. Folglich wurde ein systematisches Review durchgefuhrt, welches Studien einschloss, die Temperaturabmilderungseffekte zwischen stadtblauen und anderen Urbanen Standorten quantitativ verglichen (n=27). Studien, die in das Review auf genommen wurden, erfassten Lufttemperaturen in verschiedenen stadtblauen Raumen, wie z.B. an Teichen, Seen oder Flussen, und verglichen diese mit Standorten in definierten Distanzen zum stadtblauen Raum oder zu einem Urbanen Referenzstandort in der gleichen Stadt. Die Meta-Analyse deutet auf einen Kuhlungseffekt von 2,5 K (CI 95% 1,9—3,2 K, p<0,01) wahrend der warmsten Monate auf der Nordhalbkugel (zwischen Mai und Oktober) hin, welcher auf stadt blaue Standorte zuruckgefuhrt werden kann, wenn Fernerkundungsdaten mit einbezogen werden. Die Kuhlungseffekte, die eindeutig auf stadtblaue Raume zuruckzufuhren sind, werden durch umgebende Umweltbedingungen, wie z.B. das Mikroklima, stadtebauliche Entwicklung, Windgeschwindigkeit, -turbulenz, -richtung, Temperatur und Luftfeuchte, aller dings deutlich beeinflusst. Somit bedarf dieses Themengebiet dringend weiterer Forschung, um Planern einen effizienten Einbezug von stadtblauen Raumen zur Temperaturabmilderung und als gesundheitsschutzender und -fordernder Faktor zu ermoglichen. Der Kuhlungseffekt von Stadtblau kann Hitzestress im Urbanen Umfeld reduzieren. Fur die Schaffung gesunder Lebensumwelten in der Stadt der Zukunft mussen gesundheitsrelevante Wirkungen von Stadtblau naher unter sucht werden, um geeignete Public Health Interventionen zu ermoguchen.

Einleitung Die Grundlage jeder gesellschaftlichen Entwicklung bildet das Wasser. Aus historischer Perspektive fanden Siedlungsgründungen vor allem an Wasserlagen statt. Diese stellten das Grundnahrungsmittel Wasser bereit, fungierten als Basis für landwirtschaftliche Produktion, erfüllten vielfältige Funktionen, wie bspw. hygienische, logistische und militärische. In der post-industriellen Stadtentwicklung wurde „Stadtblau“ (Kistemann et al., 2010) als attraktiver Standortfaktor von Planern wiederentdeckt (Breen und Rigby, 1996).

The idea that nearby nature stimulates people to be more physically active is quite popular. In this chapter the literature regarding the link between physical activity and the residential environment is scrutinized. More specifically, after introducing the main concepts and a theoretical framework the evidence regarding three categories of activity is examined: physical activity in general, walking and cycling (mainly by adults), and outdoor play by children. Overall activity is deemed important because of its link to total energy expenditure, and thereby health. However, the other two categories are more likely to be linked to green aspects of the environment. Also attention is paid to the possibility that activity undertaken in a natural environment is especially beneficial for one's health. At the end of the chapter conclusions are summarized, directions for future research are proposed and policy recommendations are given, as far as possible given the current state of affairs.