Tool for assessing health and equity impacts of interventions modifying air quality in urban environments

Citation for this paper:

Cartier, Y., Benmarhnia, T., & Brousselle, A. (2015). Tool for assessing health and equity

impacts of interventions modifying air quality in urban environments. Evaluation and

Program Planning, 53, 1-9. https://doi.org/10.1016/j.evalprogplan.2015.07.004.

UVicSPACE: Research & Learning Repository

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Tool for assessing health and equity impacts of interventions modifying air quality

in urban environments

Yuri Cartier, Tarik Benmarhnia, & Astrid Brousselle

February 2015

© 2015 Yuri Carier et al. This is an open access article distributed under the terms of the

Creative Commons Attribution License.

https://creativecommons.org/licenses/by-nc-nd/4.0/

This article was originally published at:

Tool

for

assessing

health

and

equity

impacts

of

interventions

modifying

air

quality

in

urban

environments

Yuri

Cartier

a,b

,

Tarik

Benmarhnia

a,b,c

,

Astrid

Brousselle

b,d,

*

a_{EcoledesHautesEtudesenSante´ Publique(SorbonneParisCite´),Rennes,France.} b

CanadaResearchChairinEvaluationandHealthSystemImprovement,Canada c

De´partementdesante´ communautaire,Universite´ deMontre´al,Montre´al,Que´bec,Canada d

De´partementdessciencesdelasante´ communautaire,CentredeRecherchedel’HoˆpitalCharles-LeMoyne,Universite´ deSherbrooke,Longueuil, Que´bec,Canada

1. Introduction

Airpollution is a majorcontributor tothe globalburden of diseaseandmortality(Balakrishnan,Cohen,&Smith,2014;Brauer etal.,2011)andisestimatedtocause1.3milliondeathsworldwide eachyear(Smithetal., 2014).Urban ambientair pollutionis a priorityforactionastheworldpopulationbecomesincreasingly urbanized (World Health Organization, n.d.-a) and as urban environments concentrate industrial and transport activities affecting air quality. Furthermore, interventions aiming at improving health may paradoxically increase health inequities and itis now recognizedbothshouldbe addressedinorder to

maximize the positive impacts of policies and interventions (Benach, Malmusi,Yasui,&Martı´nez, 2012). Itis thereforestill necessarytoincludetheassessmentofequityinpolicyevaluation. Therecognition thatpoliciesandinterventions, insectorsother thanthehealthsector,haveanimportanteffectonairqualityand ultimately health, increases theneed toprovide managers and policy agents, in various occupational sectors, with tools and informationtohelpthembetterassesstheimpactofinterventions. Infact,publichealthisbecomingmoredeeplyintegratedwithin city policymakingand programming,and is likely togain even moreimportanceinthecoming yearswithsuchmovements as Health in All Policies (HiAP) (World Health Organization & Government of South Australia, 2010) and the WHO’s Healthy Citiesnetworks(WorldHealthOrganization,n.d.-b)emphasizing the needfor increasing positiveimpacts on health but alsoon socialinequities.Bothmovementspushforgreaterintersectoral collaboration within governments in order to achieve health objectives,andguidanceisneededtohelpanticipateandassessthe

ARTICLE INFO Articlehistory:

Received3October2014 Receivedinrevisedform3July2015 Accepted5July2015

Availableonline9July2015 Keywords: Airpollution Health Equity Policy Evaluation Assessment ABSTRACT

Background: Urbanoutdoorairpollution(AP)isamajorpublichealthconcernbutthemechanismsby whichinterventionsimpacthealthandsocialinequitiesarerarelyassessed.Healthandequityimpactsof policies andinterventionsare questioned,but managersand policy agentsinvariousinstitutional contextshaveveryfewpracticaltoolstohelpthembetterorientinterventionsinsectorsotherthanthe healthsector.Ourobjectivewastocreatesuchatooltofacilitatetheassessmentofhealthimpactsof urbanoutdoorAPinterventionsbynon-publichealthexperts.

Methods:Aniterativeprocessofreviewingtheacademicliterature,brainstorming,andconsultation withexpertswasusedtoidentifythechainofeffectsofurbanoutdoorAPandthemajormodifying factors.Totestitsapplicability,thetoolwasappliedtotwointerventions,theLondonLowEmissionZone andtheMontre´alBIXIpublicbicycle-sharingprogram.

Results:Weidentifythechainofeffects,sixcategoriesofmodifyingfactors:thosecontrollingthesource ofemissions,thequantityofemissions,concentrationsofemittedpollutants,theirspatialdistribution, personal exposure, and individual vulnerability. Modifiable and non-modifiable factors are also identified.Resultsarepresentedinthetextbutalsographically,aswewantedittobeapracticaltool, frompollutionsourcestoemission,exposure,andfinally,healtheffects.

Conclusion:ThetoolrepresentsapracticalfirststeptoassessingAP-relatedinterventionsforhealthand equityimpacts.Understandinghowdifferentfactorsaffecthealthandequitythroughairpollutioncan provideinsighttocitypolicymakerspursuingHealthinAllPolicies.

ß2015TheAuthors.PublishedbyElsevierLtd.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

* Correspondingauthorat:DepartmentofCommunityHealthSciences,Charles LeMoyneHospitalResearchCentre,UniversityofSherbrooke,150PlaceCharles LeMoyne,Room200,P.O.Box11,Longueuil,QC,CanadaJ4K0A8.

E-mailaddress:astrid.brousselle@usherbrooke.ca(A.Brousselle).

ContentslistsavailableatScienceDirect

Evaluation

and

Program

Planning

j ou rna l h ome pa ge : w w w. e l se v i e r. co m/ l oc a te / e v a l pro gpl a n

http://dx.doi.org/10.1016/j.evalprogplan.2015.07.004

0149-7189/ß2015TheAuthors.PublishedbyElsevierLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/ 4.0/).

impact of interventions on air quality and health in urban environments(Benmarhniaetal.,2014).Someacademicliterature has highlighted different policies that can be implemented to reduceairpollutionlevelsinurbanareas.Thepoliciesthathave beendocumentedincludeforinstancepollutantregulations(e.g. lead banning), low emission zone implementation, or speed limitation.Yetthereisstillalackofstudiesevaluatingthehealth and equity impacts related to policies aiming to reduce air pollution(Gileset al.,2011;Henschelet al.,2012;Wang, Xing, Zhao,Jang,&Hao,2014)andfurtherevidenceinrelationtothe effectivenessofpoliciesdescribedaboveisstillneeded.

The objective of this article is to propose a tool, designed primarilyfor non-health experts (thoughpublichealth experts mayalsofindituseful),tosupporttheminthehealthandequity assessmentof policiesand interventionsaffectingair pollution. Thistoolsaimsatidentifyingthevariousmodifiablefactorsthat can be mobilized to increase positive impacts of policies and interventions.It can be used by urban planners, health policy decisionmakers,and othermunicipalauthorities who maynot necessarilyhaveorneedsophisticatedepidemiologicalmodels.

Three domainsofresearchweremobilizedtobuildthetool: publichealth,withitslongstandinganalysisonhealth determi-nants; air pollution research, which analyzes contributors to pollutionandtheirimpactsonhealthandequity;andevaluation, withitsimportantworkonlogicanalysis.Thetoolhasbeentested ontotwointerventions:theLowEmissionZoneinLondon,andthe publicbikesharingsysteminMontreal.

2. Methods

Tobuildthetool,theauthorsfirstconductedascopingreviewof theliteratureofairpollutionwithabroadperspective,including sourcesofairpollution,airpollutioninterventions,and comple-mentarysubjectssuchasexposuremeasurement, greenspaces, and behavior. Keywords,titles, and abstracts weresearched in PubMed, Cochrane Library and Embase to identify relevant publications (see Supplemental material for keywords). The abstractsofallstudieswerereviewedtodetermineinclusion.In addition,thereferencesectionsofstudiesidentifiedinthisway werehand-searchedforadditionalstudies.No restrictionswere putondate,geographicallocation,orlanguageofpublication.

Weusedaniterativeprocesstoidentifyabasiccausalpathfor airpollutionin urbanareasfromsources tohealth andthen to equityeffects,incorporatingalltypesofpollutantsand forboth acuteandchronichealtheffects.Thetoolcanbeassimilatedtoa conceptual framework in direct logic analysis (Brousselle & Champagne,2011;Rey,Brousselle, &Dedobbeleer, 2012; Trem-blay,Brousselle,Richard,&Beaudet,2013).Logicanalysisusually encompassesthreesteps:(1)thebuildingofthelogicmodelofthe intervention;(2)thebuildingoftheconceptualframeworkbased onscientificknowledge;(3)thecomparisonofthelogicmodelto the conceptual framework, with the objective to improve the intervention and to orient the evaluation. Therefore, the tool, which correspondsto step2 of logic analysis (i.e.building the conceptualframework),representsthecausalpathfromemitting sourcestohealtheffectsandthemodifyingfactors.Thisprocess was iterative as we drafted, based on our first readings, a frameworkthatwasusedtoanalyzethenextarticles.Therewas aniterativeprocessofbrainstormingamongthethreeresearchers andreviewoftheliteraturetoimprovethemodelthroughseveral cycles.Wealsoidentified,duringourreadings,various interven-tionsaffectingairquality.Ananalysisoftheseinterventionswas systematically conducted to challenge and complement the categoriesthat wereidentified in thecausalpathas havingan influenceonhealthandequity(seeTable1).

Thistoolcanbeused first,todesignthelogicmodelof the intervention (step one of logic analysis); second, to identify relevant questions for the evaluationof the intervention; and third, to identify awareness-provoking questions for the improvementoftheintervention.Inordertotestits applicabili-ty,thetoolwasappliedtotwointerventionsinurbanareas.The first, the London Low Emission Zone, covers most of Greater Londonandimposesadailychargeonheavyvehiclesthatdonot meet emission standards (Transport for London, n.d.). Its principal objective is to reduce air pollution. The other intervention, whose principal objective is encouraging active transport but which could have an indirect impact on air pollution,istheMontrealbicycle-sharingprogram‘‘BIXI’’(BIXI, n.d.).BIXIallowssubscriberstoborrowandreturnbicyclesfrom stands located throughout the city. These interventions were

Table1

Classificationofvariousurbaninterventionsaffectingoutdoorairpollution-related health,accordingthefactorstheytargetandtheleveloftheiraction.

Levels ofaction

Factorstargeted Interventions

Sources Regulatory context

-Banoningredientsor technologies

-Banonenergysource(e.g.coal) Demand -Energypricing

-Fuelpricing -Ecotaxes

Urbandesign -Limitingsprawl(mixed-use neighborhoods)

-Developingpublictransport Behavior -Carbuybackincentives

-Lowemissionzones Emissions Regulatorycontext -Airqualitymonitoring

-Airqualitystandards -Fuelemissionstandards -Industrialemissionstandards -Engineretrofitting

Urbandesign -Limitingsprawl -Lowemissionzones

Behavior -Carpools,walking,biking,public transportinitiatives

-Discourageengineidling -Lowemissionzones -Speedlimits Concentration Topography/

weather

Architecture -Buildlowerbuildings -Setbuildingsbackfromroads Greenspaces -Increasedensityofgreenspaces

-Favorshrubsandtrees Spatial

distribution

Urbandesign -Trafficrouting/calming measures

-Zoning

Greenspaces -Situategreenspacesinhighly pollutedareas

Behavior -Restrictsolidfuelburningin denselypopulatedzones Exposure Behavior -Voluntaryinformationsystems

-Walking/bikingpathsseparated fromroutes

Vulnerability Age

Comorbidities -Physicalactivityinterventions -Nutritioninterventions SES -Employment/education interventions Other exposures -Occupationalinterventions Healtheffects (endpoint) -Secondaryprevention -Healthcareinterventions Y.Cartieretal./EvaluationandProgramPlanning53(2015)1–9

chosenbecausetherewassufficientdocumentationforanalysis, andbecause theyare representative of thekinds of interven-tionsthatarecurrentlybeingputintoplaceinurbansettingsin developed countries (Giles et al., 2011). Using the tool, the interventions were analyzed in order to identify relevant evaluationquestions andelementsthatcouldhelpinfostering theirpositiveimpactsonhealthandequity.Adialecticprocess questioningeachoftheamenableelementswasusedtoidentify furtherpertinentquestionsforimprovingtheintervention.The toolandtheanalyseswerepresentedtoandimproved bytwo publichealthexperts.We presenttheresultsheretoillustrate theinterestandapplicabilityof thetool.

3. Results 3.1. Thetool

In thetool (see Fig. 1)are factors that act on the emitting sourcesofpollution,factorsthatcanmodifytheconcentrationof air pollutants onceemitted,factors thatcan modifythespatial distributionofpollutants,andfinally,thefactorsthatmodifythe relationship between exposure and health effects, otherwise knownasvulnerability.Factorsthatareamenabletointervention areshadedwhileun-modifiablefactorsareleftwhite.Wehavealso interpretedsomefactorsasbeingeitherverydifficulttointervene

Emitting sources

Pollutants

Exposure

Health effects

Behaviors: Use of private or public transport, driving behavior, to heat home with solid fuels

Factors modifying sources and/or emissions

Regulatory context: air quality standards, vehicle emissions regulations, fuel quality standards, chemical bans Demand: demographic trends, local and global economic trends, natural resources

Urban planning and transportation management: sprawl, transit network design and fleet type

Topography: shape of land can hinder or facilitate dispersion Weather:

• heat and sunlight enable production of O3 • wind disperses pollutants • cold weather can cause

inversion

Green spaces: density • Reduce concentrations by

absorbing pollutants (PAHs, O3, heavy metals) Architecture: High buildings and narrow roads concentrate roadside pollution

Age

Factors modifying spatial distribution

How do the following vary spatially in an urban area?

Factors modifying concentration

Green spaces

Zoning and urban planning Traffic routing

Behaviors Regulatory context Architecture Topography Weather Demand Stationary sources: - Industry - Home heating Mobile sources: - Transport Primary pollutants Secondary pollutants Modifiable Partially modifiable Non-modifiable

Factors modifying vulnerability

Comorbidities Neighborhood SES

Behaviors (e.g. pollution avoidance)

Factors modifying personal exposure

uponorthatcanonlybeinterveneduponincertaincontexts;they arepresentedinstripes.

3.2. Factorsmodifyingsourcesand/oremissions

Totheextentthatairpollution’soriginsaremostlyman-made, thefactorsthataffectthesourcesandemissionsofairpollutionare also related to how people and institutions govern the use of technology, natural resources, and space. These factors are classifiedinterms ofregulations, demand,urbanplanning, and behaviors,butitisimportanttonotethatthecategoriesareflexible andfactorswithindifferentcategoriescaninfluenceeachother. 3.2.1. Regulatorycontext

Mostindustrializednationshaveasetofregulationsinplaceto insureadequateairquality(Gilesetal.,2011)thatcanvaryfor differentsourcesofpollution (transport,industry,heating,etc.). Theseregulations cantaketheformof aban on certainagents (Kuhlbuschetal.,2013),suchasleadingasoline;(VonStorchetal., 2003) or a technical requirement, such as three-way catalytic convertersincars(Farrauto&Heck,1999;Merget&Rosner,2001). Therearealsostandardssetbygovernmentalagenciesforlevelsof pollutants (Bell, Morgenstern, & Harrington, 2011). The most important of these is the Clean Air Act in the United States (Lawrence,1971),regulationinitiallypassedin1970andamended periodicallyeversince(Samet,2011)thatrequiresstatestoadopt andenforceplanstoachieveandmaintainpollutionlevelsbelow federalstandards(UnitedStatesEnvironmentalProtectionAgency, n.d.).Lastly,thechoiceofametropolitanareaofoneormoremain sources of energy also plays a large part in the emission of pollutants(Mena-Carrascoetal.,2012).

3.2.2. Demand

Economic,political,andculturalfactorscanshapetheneedsof anurbanareaintermsoftransport,heating,orindustry(Lioy& Georgopoulos,2011).Forexample,acitythatishighlydependent ontourismmayprioritizepublictransportation,greenspacesand walkabilityinitscenterandpushindustrytotheoutskirts.Cultural valuesassociatedwithcarownership,forexample,cangenerate high demand for cars in proportion to other methods of transportation.Globaleconomictrendsliketheincreasingreliance onimported goodscanalso impactemissionsovertime (Perez etal.,2009).

3.2.3. Urbanplanning

Urbansprawl,whichinandofitselfisdependentonfactorslike topography,demographicshifts,andvaluescanleadtoincreased demandforcarsandlongerjourneysincars(Frumkin,2002).The designofthepublictransportationsysteminacitywillalsoaffect demandfor privatetransportation(Mena-Carrascoet al.,2012). Different public transportation systems will be more or less pollutingdependingontheirenergysources.

3.2.4. Behavior

Thebehaviorofresidentswithinanurbanareaisconditioned by all of the preceding factors. Residents may have several optionsfortransportation(bicycle,motorcycle,bus,train,orcar) orforheatingandthefrequencywithwhichtheyuseeachwill affectthetotalemissionsfromeachsource(Krizek,2003;Litman, 2005).

Intheschematictheabovefactorsarelinkedbothtothesource andtoemissions,inthesensethattheyaredeterminantsforthe veryexistenceofthesource,ortheycanmodifythequantityofair pollutantsemitted.Forexample,policiesbanningfueladditives workon the source, while dense multi-use neighborhoods, by minimizingcaruse,workontheemissions.

3.3. Factorsmodifyingconcentrations

Oncepollutantsareemitted,theydisperseintheatmosphere. Thereareseveralnaturalandman-madefactorsthatinfluencehow pollutantsaredispersed,trapped,orabsorbed.

3.3.1. Topographyandmeteorology

Theshapeofthelandinanurbanareacanhelporhinderthe dispersion of pollutants into the atmosphere,often workingin conjunctionwiththeweather(Wallace,Corr,&Kanaroglou,2010). Valleys lower wind speed, slowing down dispersion, while a coastal location benefits from higher wind speeds (Hertel & Goodsite,n.d.).Inparticular,coldweatherinavalleycancreate inversion, trapping air pollution near to the ground. Heat and sunlight enable the transformation of NOx and subsequent

productionofozone(Ranetal.,2009). 3.3.2. Greenspaces

VegetationabsorbssomepollutantslikePAHsandozone,and foliageiscapableoftrappingandabsorbingsuspendedparticulate matter(Vida,2011).Thesurfaceareadevotedtogreenspacesina city can thus affect the concentrations of these pollutants. However,notallgreenspaceisequal.Forexample,Peng,Ouyang, Wang,Chen,andJiao(2012)foundthatthetypeofvegetativecover playsa rolein howmuchpollutionis absorbed;woodlandand tree–shrub–herbsettingstrappedmorePAHthangrassland. 3.3.3. Architecture

Architectural factors can include (but are not limited to) buildingmaterials,shape andsize,distance fromroadsor road width. Colvile and colleagues (Colvile, Hutchinson, Mindell, & Warren, 2001) mention that narrow roads bordered by high buildingsmitigatewind speeds,raisingconcentrationsof pollu-tants from vehicleemissions. By contrast, open roads disperse vehicleemissionsmoreeffectively.

3.4. Factorsmodifyingspatialdistribution

Allofthefactorsthataffectsources,emissions,and concentra-tionshavethepowertoaffectthespatialdistributionofpollutants (Gilbert,Goldberg, Beckerman, Brook, & Jerrett, 2005; Ragettli, Ducret-Stich,etal.,2014;Ross,Jerrett,Ito,Tempalski,&Thurston, 2007),dependingonhowthesefactorsactacrossanurbanarea. Spatialdistributionherereferstointra-urbanexposure heteroge-neityanddoesnotencompassthedifferentialdistributionthatcan occur betweena cityand itssurroundings (Ragettli,Tsai,et al., 2014).Thefollowingisaselectionofexamplestoillustratehow thesedeterminants may beacted upon in orderto modifythe spatialdistribution.

3.4.1. Trafficrouting

Highwaysandotherroadswithhightrafficdensitymaynotbe evenlydistributedthroughoutthecity(Ducret-Stichetal.,2013). Thequestionofwheretunnelsandoverpassesarebuiltalsoalters thedistributionofpollutionconcentrationsinacity.Trucks,for example,mayonlybeauthorizedtopassthroughcertainroutes andthis,too,willmeanvehicleemissionswillbehigherincertain zones.

3.4.2. Greenspaces

Neighborhoods may have differentialsurface areas of green spaces(Lakes,Bru¨ckner,&Kra¨mer,2013),differentialproximityof greenspacestoroadways,ordifferenttypesoflandcoverinsuch spaces(DeRidderetal.,2004;Wolch,Byrne,&Newell,2014).Any of the aforementioned variations will reduce concentrations of pollutantstoagreaterorlesserextentasdiscussedabove.

Y.Cartieretal./EvaluationandProgramPlanning53(2015)1–9 4

3.4.3. Zoningandurbanplanning

Residences,nursinghomes,orschoolsmaybesitedfarawayor closetoindustrialareasordenselytraffickedroads.Theymaybe well-orill-servedbypublictransportationroutes.

3.4.4. Behavior

As with behaviors affecting the source, behaviors here are highly constrained by themore upstream factors listed above. Differentneighborhoodsmayhaveaccess todifferentmodesof transportationor heating sources (Cohen, Boniface,& Watkins, 2014), leading for example to distribution of wood-burning-relatedpollutionthatiscenteredinneighborhoodswithoutaccess togasheating.

3.5. Factorsmodifyingpersonalexposure

Behavior.Anindividual’sexposuretoairpollutiondependson their behaviorsin time and space, alsoknown as time-activity patterns (Blangiardo, Hansell, & Richardson,2011; Dons et al., 2011).Additionally,individualswithincreasedvulnerabilitytoair pollution(suchasasthmatics)maychangetheirbehaviorstoavoid exposing themselvesto highlevels of air pollution (Buonanno, Stabile,&Morawska,2014).

3.6. Factorsmodifyingvulnerability

Asresearchonsocialdeterminantsofhealthandenvironmental justice have demonstrated, the most socially and materially deprivedarealsothose whowillexperiencea largerimpacton theirhealthforthesameexposure(O’Neilletal.,2003).Indeed, twoindividualsmaybeexposedtosimilarairpollutionlevelsbut thehealtheffectsforonemaybemorepronounced,duetoother social determinants of health such as co-morbidities, age, or socioeconomic position. Vulnerability refers to individual and contextualfactorsthatmodifytherelationshipbetweenagiven person’sexposureandthehealtheffectstheymayhave(Forastiere etal.,2007).

Italsomustbenotedthatthehealtheffectsassociatedwithair pollutioncanbecausedbymanyotherfactors,atleastsomeof

whichareaddressedbyotherinterventions.Forexample,exposure toPMislinkedtoashort-termincreaseinheartattacks(Peters, Dockery,Muller,&Mittleman,2001)butthereareseveralother determinants of heart attacks, including one’s level of physical activity(Ahmed,Blaha,Nasir,Rivera,&Blumenthal,2012), soa successful physical activityintervention may reducea person’s vulnerabilitytosufferinganairpollution-relatedheartattack.

Inordertointegratevulnerabilityfactorsdocumentedinthe epidemiologicliterature,existingframeworkssuchasthe PROG-RESSframework(NationalCollaboratingCentreforMethodsand Tools, 2014)can be used.This framework proposes a range of vulnerability factors (e.g. place of residence, education, social capital...)whichcanhelptoanalyzehowvarioushealthand non-healthinterventionsaffecthealthequity.

Theonusisthusoninterventionstargetingspatialdistribution totakevulnerabilityintoconsideration,asthiswillplayarolein determiningthespatialdistributionof healthbenefitsfromthe intervention—a spatially homogenous intervention could offer disproportionatelysmallhealthbenefitstothemorevulnerable.

Thetoolisusedtoidentifyrelevantquestionsfortheevaluation oftheintervention,toidentifyquestionsfortheimprovementof theintervention(seeTable2)ingeneralandforthetwofollowing casestudies,theLEZandtheBIXI.

3.7. Twocasestudies

Two interventions are analyzed using the tool, one that explicitlyaimstoreduceairpollution(theLondonLowEmission Zone),andoneinterventionwhoseprincipalaimisnottoreduce airpollutionbutwhichmayhaveanimpactonit(BIXI,Montreal’s publicbicyclesharingsystem).

3.7.1. LondonLow-EmissionZone

In 2008Londonlauncheda LowEmissionZone(LEZ), which coversmostoftheareaknownasGreaterLondon.Thezone,which is ineffect24hoursaday,imposesa dailychargeforalllarger vehicles(excludingcarsandmotorcycles)thatdonotmeetEuroIV emissionstandards.Thechargesaredesignedtodiscourage non-compliantvehiclesfromenteringintothezone:

£

100forvansand

Table2

Questionstobeawareofforinterventionevaluationandimprovement,illustratedfortwointerventions.

Generalquestions BIXI LEZ

Sourcestopollutants Questionforinterventionevaluation:Does theinterventionhaveanimpactonsources ofemissions?

DoesBIXIreducetheuseofcars? Withinthegeographicalareadefinedby theLEZ,hasthenumberofprohibited vehiclesdecreased?Aretheresome behaviorchangesthataremoreeffectiveat achievingtheseimpactsthanothers? Questionforinterventionimprovement:Is

itpossibletomodifytheinterventionsoas tofurtherreduceemissions?

Whatpartnersorareasshouldbe targetedinordertofurther reducecaruse?

Howcanthemostfavorablebehaviorsbe encouragedbytheintervention? Pollutantstoexposure Questionsforinterventionevaluation:Are

somegroupsmoreexposedtopollutants, duetotheintervention?Doesthe interventionreduceexposureforthose groupswhopreviouslyhadthehighest levelsofexposure?

AreBIXIusersmoreexposedto pollutants?

Whichgroupswouldbemoreexposedto pollutants?Isthedecreasedexposurein thecitycenteroffsetbyanincreased exposureatthelimitsoftheZone?

Questionforinterventionimprovement: Whatcanbedonesothatreductionsin exposuretopollutantsaregreaterforthose areaswithhigherinitialexposure?

Isitpossibletobuildbikepaths awayfrommajorroadsinorder tominimizecyclists’exposureto roadsidepollutants?

Canmechanismsbeputinplaceinareas alongthebordersoftheZoneinorderto minimizepopulationimpacts? Exposuretohealth

effects

Questionforinterventionevaluation:Does theinterventionaffectthemostvulnerable populations?

NotpertinentforBIXI Wherearevulnerablezoneslocatedwith respecttomajorroutes?Howarethey affectedbytheLEZ?

Questionforinterventionimprovement: Whatcanbedonetoreducetheburdenfor vulnerablezonesandpopulations?

NotpertinentforBIXI Whatcanbedonetoreducetheburdenfor vulnerablezones?

minibusesand

£

200fortrucksandbuses.ParalleltotheLEZ,there isafilterscheme.Non-compliantvehiclescanbefittedwithan approvedfilterandsubsequentlyundergoacertificationprocessto beapprovedforfreeentryintotheLEZ.Intargetingonlylarger vehicles,theinterventionaffectsbusinessesandorganizationsand putsalimitedburdenonindividuals.However,thebenefitshave thepotentialtobeenjoyedbyeveryoneintheLEZ.

TheLEZaimstoincentivizethephasing-outoftheoldestand mostpollutingheavygoodsvehiclessothattheremainingvehicles ontheroademitlowerlevelsofairpollution,specificallyparticulate matterandNOx.Itisthusaninterventionthataffectsonesourceof airpollution.Allowingvehiclestoretrofittheirexhaustpipeswith filtersactsontheemissions.Finally,thisinterventionactsuponthe spatial distribution of pollution by aiming to lower roadside pollutants, with the greatest impact being on the most highly traffickedroads.Furthermore,theintervention’sfavorableimpact onemissionshasthepotentialtoextendbeyondthegeographical boundariesoftheLEZ,unlesscompanieswithfleetsofthesevehicles opt exclusively to reorganize routes so that non-compliant vehiclesremainincirculationoutsideoftheLEZ.Doingsowould alterthespatialdistributionofpollutantsbyconcentratingthe heavily polluting vehicles outside of the LEZ and potentially increasing exposure to pollution for populations residing just insideitsboundaries.

3.7.2. Applicationforevaluationandintervention

For each question there are implications for intervention depending on the response that is found. The regulatory component (filter retrofitting scheme) and the urban planning component(dailychargescheme)oftheLEZbothaimtochange behavior.Towhatextentdotheydoso?Dobehaviorchangesaffect thenumberofheavygoodsvehiclesontheroadandhowmuch pollutionisemittedfromheavygoodsvehicles?Whenfacedwith theintervention,weconsiderthatorganizationsandbusinesses havefive choices:theycan replacetheir vehicles, retrofittheir existing vehicles, reorganize their fleet so that non-compliant vehicles stay out of the zone, abandon their vehicles without replacingthem,orenterthezonewiththeoldvehiclesandpaythe charge.Theprogressively tighteningstandards meanthatthese decisionsmustbemadeeachtimenewrequirementsemerge.Are theresomebehaviorchangesthataremoreeffectiveatachieving theseimpacts than others? If so, how can the most favorable behaviorsbeencouragedbytheintervention?

How arethebenefitsoftheLEZ,air pollution-wise,spatially distributed?Inparticular,whatisthecomparativereductionofair pollution for vulnerable vs. non-vulnerable areas? In order to answer this question, it is necessary to locate zones where populationsarevulnerable.Whereistrafficinandaroundthese zones?Itmightbeconceivabletoraisethedailychargesforentry pointsintheLEZwhereroutespassthroughvulnerableareas,in ordertoencouragedriverswhochoosetoentertheLEZwiththe oldervehiclestotakeanalternateroutethatwouldhavealower impactonhealth.Doloweringthenumberofandtheemissions from heavy goods vehicles improve health outcomes for the Londonpopulation?Whatisthedistributionofthisimprovement; isitequitable?Whatotherfactorsconcurrenttotheintervention couldhaveanimpactonpeople’svulnerability?

3.7.3. BIXIMontreal

The Montreal public bicycle sharing system BIXI was introducedin2009.FromApriltoNovember,BIXImakesbicycles availableatdockingstationsforacheckoutfeeof$7for24h,$15 for72h,$31.25for30days,and$82.50fortheyear.Paymentof thecheck-outfeeentitlestheuserto30minfreeofchargefor eachride,withadditionalhourlyfeesthereafter. The interven-tion is thus designed for frequent short-term use, consistent

with its stated purpose as a ‘‘real means of urban transport’’ (bixi.com).

Built environmentinterventionssuchasBIXIoftenhave the principal aim of improving health through the pathway of increasing physical activity (Fishman, Washington, & Haworth, 2012;Fuller,Gauvin,Kestens,Morency,&Drouin,2013)butmay alsohaveaneffectthroughthereductionofoutdoorairpollution, whichisalsoofinterestfordecisionmakers.Infact,bothpathways contributetoreducingcardiovascularandrespiratorydisease.Itis thus appropriate for us to analyze theintervention within the frameworkofourcausalmodel.

TheprimarymechanismoftheBIXIinterventionoperateson thesourcesofemissions,throughbehaviorchange.Itis hypothe-sizedthatoptingfortheBIXIoverone’scarormotorcycleprevents emissionsbythesevehiclesontheroadsthatuserswouldtake. This,in turn,wouldreduce exposuretoroadside pollutantsfor thoselivingorworkinginproximitytosaidroads.Consequently, onecouldhypothesizeadecreaseinairpollution-relateddisease anddeath,althoughthedecreasemaybedifferentialaccordingto people’svulnerability.

ThispathwayistheonlywayforBIXItohaveanimpactonair pollutionitselfanditislimitedspecificallytothosewhoswitch fromcars and motorcycles.However, the interventioncan also haveeffectsonexposureandvulnerabilityforitsusers.BIXIusers riskhigherexposuretoroadsidepollutants(thoughtheevidenceis not conclusive, Kingham, Meaton, Sheard, & Lawrenson, 1998; Rank, Folke, & Homann Jespersen, 2001), negatively impacting health.Asstatedearlier,usingBIXIalsoincreaseslevelsofphysical activity,whichhasdirectbeneficialimpactsoncardiovascularand respiratoryhealth,therebyloweringvulnerabilitytoairpollution’s negativeeffectsoncardiovascularandrespiratoryhealth. 3.7.4. Applicationforevaluationandintervention

DoesBIXIchangebehavior?Amodalshiftfromprivatetransport to BIXI, if fulfilled,will have a positiveimpact on levels of air pollution,vulnerability,andhealth.Thereisnoairpollutionimpact whenothermodalshiftsoccur,especiallywhentheshiftisfrom walkingorprivatelyownedbicycles;therefore,itisessentialfor evaluatorstodeterminetowhatextenttheinterventionismeeting thisobjective.Whoadoptsitmost—cyclists,motorists,peoplewho take public transportation, pedestrians? There is some data to indicate that the modal shift to BIXI is occurring in higher proportions from public transportation than from cars (Fuller etal.,2013).Howcanmotorists,thepeoplewhowouldbringthe greatest benefit to the intervention in terms of air pollution reduction,beencouragedtoswitchtoBIXI?Newdockingstations couldbeplacedinareaswherepeoplearelikelytocommutebycar forrelativelyshortdistances,perhapsduetoinconvenienttransport links.Anotherpossibilityistoengageuniversitiesandworkplacesas partnersinordertonormalizeamasschangefromcarstoBIXIeach year at the start of the season (mid-April). However, bicycle redistribution services will need to be coordinated with such measures,orelsethelackofdockingspacesonarrivalinthemorning andofbicyclesintheeveningwilldiscourageusers.Thisraisesthe questionofhowwecanredistributebicyclessothatbothbicycles anddockingstationsareavailable,andhowwecandosoinsucha waythatdoesnotincreasepollution,sinceredistributionisdone usinglargetrucks.HowcanwelowerexposuretopollutionforBIXI users?Whilenotwithinthepurviewoftheintervention,thecity maywishtotakemeasureslikebuildingbikepathsawayfrommajor roadsinordertominimizecyclists’exposuretoroadsidepollutants. 4. Discussion

This tool may be useful at differentlevels: for intervention planningandevaluation.Teasingapartthedifferentmechanisms

Y.Cartieretal./EvaluationandProgramPlanning53(2015)1–9 6

that comprise an intervention’s effects along the causal path enablesthedevelopmentofquestionsforevaluationandpotential recommendationsforactioninathoroughandsystematicmanner. Whilebothmodifiableandnon-modifiablefactorsareincluded inthetool,weconsiderthatthemostimportantfactorslistedare thosethatcanbetargetedbyinterventions.Indeed,any interven-tiontoreduceairpollutionshouldbeactingonatleastoneofthe factorsinthismodel.Thosefocusingonreducingoverallexposure willactmostlyonthoseupstreamfactorsclassifiedundersources, emissions,andconcentrations.Interventionsactingonfactorsthat modifyspatialdistributionandvulnerability,ontheotherhand, are particularly relevant to equity concerns, because they are rarelyuniformandthisdifferentialnaturegeneratesinequalities (Benmarhniaet al.,2014). In particular,interventionsactingon spatialdistributionshouldconsiderbothequityofexposureaswell asequityofhealthbenefitsrelatedtopopulationvulnerabilities, becauseaninterventionthatsucceedsindecreasingthe heteroge-neityinexposureexperiencedoveranurbanareamaystillreap unequalhealthbenefitsduetodifferentialvulnerabilities( Cesar-onietal.,2012).

Twointerventionswereusedascasestudies.Previousworkhas conductedevaluationrelatedtobothLEZandBIXI.Forexample, aboutthe LondonLEZ, somestudies assessed its effects on air pollutionreduction(Ellison,Greaves,&Hensher,2013)andsome studies about health effects are expected (Kelly et al., 2011). EvaluationstudiesrelatedtothehealtheffectsofLEZaroundthe worldaregreatlygrowinginrecentyears(Morfeld,Groneberg,& Spallek,2014)andourworkistimelytoconceptuallyhelpfurther empiricalevaluation studies and interventionimprovementsas well.

Inaddition,furtherworkcouldextendourapproachtobroader publicpolicyanalysisthatconsiderthewhole processofpublic decision making (Howlett, 2010; Knill & Tosun, 2012; Knill, Schulze,& Tosun, 2011; Sabatier &Weible, 2014) by setting a policyagenda,identifyingchallengesforimplementation evalua-tion studies and discuss uncertainty issues (Manski,2013) for example.

Thistoolhassomelimitationsthataffectitsgeneralizabilityand transferability.Firstofall,itaddressesurbanoutdoorairpollution withina developed countrycontext.While theepidemiological burden of air pollution is higher in developing countries, the majority ofthe literaturefound wasin the North Americanor Europeancontext.Interveningonairpollutioninthecontextofa developingcountrycouldalsobenefitfromtheconstructionofa specific tool like that which we present here, taking thelocal evidencebaseasthestartingpoint.Secondly,spatialdistributionis accountedfor,butnottemporaldistribution,whichcanalsoaffect exposure (Brunekreef & Holgate, 2002). Evidence on temporal distributionmaybeincorporatedintolocaladaptationsofthetool, againdependingontheavailabilityofdata.Lastly,forthepurposesof thismodel,thecityisaspacewithclearlydefinedboundaries.This isa necessary simplificationgiven thatinterventions(especially policies)arecarriedoutwithinanadministrativesubdivision,but therealityisadmittedlymorecomplexandotherexternalfactors canaffectairpollutionwithinacity.

5. Conclusion

Thegrowingneedtointegratehealthinto citypolicymaking necessitatesathoroughandeffectivewayofexamininghowurban interventionscanbeevaluatedandplannedtomaximizehealth and equity. People have the means to influence the way interventionsaredesignedinordertoincreasetheintervention’s positiveinfluence on healthand equity. In fact,urban environ-mentsaremajordeterminantsofpopulationhealth.Nevertheless, thosewhohavethepowertoinfluencethewayinterventionsare

designedarenotnecessarilypublichealthexpertsandthereisa needtohelpthemthinkthroughandconceptualizethehealthand equityaspectsofinterventionsinurbanenvironments.Thetoolwe designed is meantasan assessment aidformunicipaldecision makersandprogramplanners.

Airpollutionhasbeenapublichealthissuesincethedawnof theindustrialage,andhassinceundergonesignificantevolutions. Extensivelegislationandtechnologicalinnovationshave contrib-utedtoimprovingairqualityandassociatedhealthindeveloped countries,buttheremaininggainstobemadeinthisareadepend ontacklinginequalitiesinexposureandvulnerabilitytopollution. 6. Lessonslearned

Thebuildingofthistoolisatthecrossingofvariousemerging andconsolidatingmovements.First,populationhealth interven-tionresearch(PHIR)(Hawe&Potvin,2009),whichpropoundsthe ideathat publichealth researchshouldreorientitseffortsfrom analyzingdeterminantsofhealthtowardfindingwaystohavean influenceonpopulationhealth.Second,theory-basedevaluation, with the growing recognition that working on theories of intervention can provideimportant insightsfor thedesign and theevaluationofinterventions.Wewantedtoproposeapragmatic tool,usefulfornon-publichealthexperts.Thisobjectiveledusto buildatoollargelyinspiredfromstep2oflogicanalysis.Wehadto make compromisesbetween itssimplicityand theexact repre-sentationofcomplexcausalpaths,whichwouldincludeseveral links and feedback loops. Nevertheless, we believe that, in its currentform,itmeetsourexpectationsinthatitwillhelpraise pertinentquestionsthatwillenablebetterdesignandevaluation ofinterventionsmodifyingairqualityinurbanenvironments. Conflictofintereststatement

Theauthorsdeclarethattheyhavenoconflictofinterest. Financialdisclosure

Theauthorshavenofinancialdisclosures. Acknowledgments

The authors would like tothank the Canadian Institutes of HealthResearchandthe‘‘Fondsderechercheensante´ Que´bec’’for fundingAstridBrousselle’sCanadaResearchChair inEvaluation and Health System Improvement (CRC-EASY). The CRC-EASY supported theexecutionofthis research.Theauthorsalsowish tothanktheEcoledesHautesEtudesenSante´ Publiqueforfunding support.ThankyoutoNolwennNoiselandDanielFullerfortheir commentsonanearlierversionofthemanuscriptandframework. AppendixA. Supplementarydata

Supplementarydataassociatedwiththisarticlecanbefound,in theonlineversion,athttp://dx.doi.org/10.1016/j.evalprogplan.2015. 07.004.

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YuriCartier,MPH,isagraduateoftheEcoledesHautesEtudesenSante´ Publiqueand WellesleyCollege.ShecurrentlyservesasScientificProjectsandPublications Coordi-natorattheInternationalUnionforHealthPromotionandEducation.

TarikBenmarhnia,PhD,isaPostdoctoralFellowwiththeMontrealHealthEquity ResearchConsortium(MHERC)attheInstituteofHealthandSocialPolicies(McGill University,Canada).

AstridBrousselle,Ph.D.,isFullProfessorattheDepartmentofCommunityHealth Sciences,UniversityofSherbrooke,andresearcherattheCharles-LeMoyneHospital ResearchCenter.SheistheholderofaCanadaResearchChairin‘‘EvaluationandHealth SystemImprovement(EASY)’’co-financedbytheCanadianInstitutesofHealth Re-searchandtheFondsderechercheenSanteduQuebec.