Health Impact Assessment: Current practice internationally

Mirko Winkler led a team that undertook a survey of 122 HIA practitioners across 29 countries. The findings highlight that:

• HIA is being used worldwide
• Capacity is concentrated at the beginner and intermediate levels, though a higher proportion of respondents from Europe reported having more than ten years of HIA experience
• there is a need for more advanced capacity building and training offerings internationally
• strengthening the policies and legal frameworks under which HIAs are undertaken remains relevant.

Twenty-four percent of respondents were from the Asia Pacific, and practices across our region are reflected in the overall results.

Health Impact Assessment: A practical guide that I wrote with Patrick Harris, Elizabeth Harris, and Lynn Kemp (Harris et al. 2007) was identified as the fifth most-used HIA guidance internationally, after WHO guides, Martin Birley’s book on HIA (Birley, 2011), and the IAIA Best Practice Principles (Quigley et al. 2006).

In general respondents were split on whether HIA’s use is continuing to increase or has stagnated, a debate that has relevance across the Asia Pacific region. Of particular important to our region, the paper emphasises that:

Finally, there is an increasing recognition of the role that biodiversity and ecosystem services play in the relationship “healthy planet, healthy people”, and the role that impact assessments play. In an outlook for the future, and additionally to providing a framework for safeguarding health in sustainable development, HIA has the potential to be contributory to the operationalisation of “planetary health”

References

Quigley, R., L. den Broeder, P Furu, A Bond, B Cave, and R Bos. “Health Impact Assessment International Best Practice Principles.” Fargo, North Dakota: International Association for Impact Assessment, 2006.

Winkler, Mirko S., Peter Furu, Francesca Viliani, Ben Cave, Mark Divall, Geetha Ramesh, Ben Harris-Roxas, and Astrid M. Knoblauch. “Current Global Health Impact Assessment Practice.” International Journal of Environmental Research and Public Health 17, no. 9 (April 25, 2020): 2988. https://doi.org/10.3390/ijerph17092988.

Harris, P., B. Harris-Roxas, E. Harris, and L. Kemp. “Health Impact Assessment: A Practical Guide.” Sydney: UNSW Centre for Primary Health Care and Equity and NSW Health, 2007.

Martin Birley. Health Impact Assessment: Principles and Practice. London: Routledge, 2011.

Health impact assessment for health promotion, education and learning

Special issue on HIA for
health promotion, education
and learning

A new issue of Global Health Promotion on Health impact assessment for health promotion, education and learning has been published. All articles are freely available as open access for a limited time.

It includes articles on diverse topics such as climate change, e-waste, local government and evaluation. Several of the articles are in French.

The issue was developed as an activity of the International Union For Health Promotion and Education's Global Working Group on HIA, and guest edited by Ben Harris-Roxas and Monica O'Mullane.

Special issue table of contents http://journals.sagepub.com/toc/pedb/24/2 

Editorial in English http://journals.sagepub.com/d…/full/10.1177/1757975917704614

Editorial in French http://journals.sagepub.com/d…/full/10.1177/1757975917712410

Editorial in Spanish http://journals.sagepub.com/d…/full/10.1177/1757975917712806

News from the Human Impact Partners: Research reports and successes!

From the HIP Newsletter, which is worth subscribing to.

 

Policy Victory! Oakland Says No to Coal, Citing Public Health Concerns

In June, the Oakland City Council voted against a plan to transport coal through a proposed bulk export terminal. A group of public health experts — including our Co-Director Jonathan Heller — released a critical report prior to the vote citing significant health risks of increased emissions of coal dust and diesel exhaust. The report played a key role in continuing public pressure and the final vote.

Council President Lynette Gibson McElhaney called for racial equity, not just in economic opportunities, but also in health outcomes, stating “It is outrageous to me that when we start talking about jobs for African Americans, for low-wage workers, they’re the dirtiest jobs, the most risky jobs, the jobs that we have to pay for with our bodies and shortened lives.” Developers tried falsely to claim that the city had a choice between jobs or protecting health and the environment, but the coal terminal would bring fewer jobs than the transport of other bulk materials through the port and these other materials pose less of a health risk for Oakland residents.

In addition to health impacts locally in Oakland, public officials were swayed by concerns over the worldwide effects of increased coal use on climate change. Emissions from the coal shipped through the proposed terminal would have constituted 0.6% of the world’s carbon budget. Senator Lori Hancock cited the public health study when she weighed in before the vote, claiming “if this happens, it will turn our state from being a worldwide leader of the growing green economy into the largest West Coast exporter of coal -- a major public health danger and greenhouse gas polluter.” HIP is proud to have contributed to this major policy win with clear public health impacts in Oakland and beyond.

Expanding Access to Preschool: Cincinnati’s Fork in the Road

HIP and our partners with the AMOS Project are excited to release The Health and Equity Impacts of Expanded Access to Preschool: Cincinnati’s Fork in the Road. The report set out to answer the question: How will expanding access to preschool affect the health and well-being of children, families, and other residents of Cincinnati?

Currently nearly half of Cincinnati’s children are starting from a disadvantage on their first day of kindergarten. The study shows that:

• Children who have access to preschool could experience fewer challenges in school, leading to higher graduation rates and decreased crime rates.
• Families could experience decreased parenting stress, child abuse, and neglect.
• Cincinnati could benefit from more workers who are able to find employment at higher wages.

In conclusion: expanding access to preschool would improve the health of Cincinnati’s children and families, making Cincinnati a healthier, wealthier and more equitable city.

Specific recommendations from the report include: 

1. Expand access to high-quality preschool to all children in Cincinnati
2. Prioritize to reach those most in need, such as children living in poverty
3. Assure high-quality preschools and teachers through adherence to preschool program training features that research has proven to be successful
4. Utilize a trauma-informed approach to discipline that incorporates an understanding of the source of the behavior problem, in preschool and beyond, rather than zero-tolerance policies such as suspensions and expulsions
5. Assure that high-quality preschools are geographically distributed throughout the city

For more information, you can read the following HIA documents:

• Executive Summary
• Full Report
• Infographic
• Appendices

 

Scheduling Away Our Health

HIP, The Center for Popular Democracy, and Working Washington released Scheduling Away Our Health: How Unpredictable Work Hours Affect Health and Well-being, a research report analyzing how unpredictable work schedules affect the physical and mental health of workers and their families. As part of this work, we conducted a focus group in Seattle, learning how erratic schedules lead to income instability and stress for low-wage workers:

“There are days I can work a long day and they’ll only schedule me 4 hours as opposed to 8 hours. And so that’s getting kind of scary when it gets down to the wire, when I really don’t have any money and I don’t know if you’re going to schedule me for 15 hours this week or 4 hours. It’s just really hard to deal with.” – Holly, retail worker

The report also includes analysis of the 2014 General Social Survey. We found that workers with less advance notice of their schedules report worse overall health and more frequent mental health problems.

The report recommends the following, to help improve the health of these workers:

• The ability to obtain advanced scheduling of 2-3 weeks
• The right to rest 11 hours between shifts
• The right to request scheduling accommodations
• The right to have stable hours week-to-week

 

Connecting the Dots to Health: LACDPH Evaluation Report 

The Los Angeles County Department of Public Health hired HIP to conduct an external evaluation of two of its recently completed Rapid Health Impact Assessments (HIAs). The goal was to learn lessons from past HIAs and inform the work of the Health Impact Evaluation Center within the LACDPH.

Our report focused on HIAs for the following two programs:

• Parks After Dark (PAD) — a comprehensive, cross-sector collaboration program designed to prevent violence and promote healthy and active living in parks.
• Second Chance Women’s Re-Entry Court (WRC) — a specialized court-based jail diversion program that provides mental health treatment, substance use disorder treatment, and other social support services.

The evaluation found that both of these HIAs:

• Helped increase local commitments to program funding
• Found impacts on health determinants
• Highlighted programs’ relationship to priority county topics
• Strengthened existing and fostered new collaborations among government agencies
• Helped change institutional mindsets and increase focus on health

You can access the executive summary and full report to read our full set of findings and recommendations from this project.

Public Health Departments in Criminal Justice Reform

“We can all agree that mass incarceration is a public health problem.” – interview participant from the California Department of Public Health

How can public health departments play a more significant role in criminal justice reform? With support from The California Endowment, we conducted focus groups and interviews with representatives from more than 20 local and state public health departments in California. We asked them about their current work related to criminal justice and what stops them from doing more. Our report — Public Health Departments in California and Criminal Justice System Reform:  Successes, Barriers, and Recommendations for Action — summarizes our findings and provides a set of recommendations for public health departments wanting to get more involved in criminal justice reform.
 

Announcements

• We’re happy to welcome Ana Tellez as our Communications Director — a brand new position for HIP! Ana will be working to broaden the reach of our work and to increase engagement with our research findings, to help fulfill our mission. 

• We’re happy to welcome back Gus Alexander, who completed a 6-month field study with us in 2015 as part of her Community Studies program at the University of California at Santa Cruz. She will be on our team for another 6 months as a Research Assistant.

• The American Planning Association (APA) recently released The State of Health Impact Assessment in Planning. The report reviews 27 planning HIAs, including several that we led or provided technical assistance on. It offers recommendations for using HIA in the planning process.

• Our research has been in the news this summer:

  • The Atlantic’s CityLab: Getting More Formerly Incarcerated People Into Public Housing
  • WBAI Pacifica Radio: Police Killings as a Public Health Issue (begins at 32:15)
  • NPR: When Parents Face Deportation, Their Children’s Mental Health Suffers

Lessons about health impact assessment: Learning by Doing

VicHealth team presenting on their
equity focused health impact assessment

Last week I attended the final day of a Learning by Doing health impact assessment (HIA) training program. Learning by Doing is a structured six-day training program run by the Centre for Health Equity Training, Research and Evaluation (CHETRE), where I work. The training is broken up into distinct stages. People learn about HIA, go away and do the steps they've learned about, then come back to reflect and learn about the next steps in the process.

The final day is always great because the different groups who have been doing their HIAs present their work and their findings. There were five HIAs conducted in this round of Learning by Doing, which included the South Western Sydney Local Health District, the NSW Department of Family and Community Services, VicHealth, Liverpool City Council, the Think+Do Tank and community representatives.

Some of the stand-out lessons from the Learning by Doing sites were:

• A lot of the value of HIA lies in highlighting and clarifying assumptions made during planning.
• A planned engagement approach is useful as part of all HIAs.
• Conceptual learning remains an important outcome of HIAs, in particular learning about health equity.
• Involving consumers in HIAs has multiple practical benefits, such as identifying alternatives and providing an understanding of  context and history.
• Scoping remains as critical as always - being rigorous but not biting off more than you can chew (it also reminded me of this paper about scoping in EIA).
• Not all barriers can be overcome; you need to be realistic about what you can achieve within the limits of an HIA.

For more on CHETRE's work on health impact assessment go to HIA Connect. The Learning by Doing approach is described in greater detail in the chapter below:

Harris E, Harris-Roxas B, Harris P, Kemp L. “Learning by Doing”: Building Workforce Capacity to undertake HIA - An Australian case study, in O’Mullane M (ed) Integrating Health Impact Assessment into the Policy Process: Lessons and Experiences from around the World, Oxford University Press: Oxford, 2013, p 99-108. ISBN 9 7801 9963 9960 Google Books link

Cross-posted from my personal blog

Communicating about equity in HIA

A great resource from SOPHIA:

The SOPHIA Equity Working Group has just released Communicating about Equity in HIA: A Guide for Practitioners. 

HIAs provide an opportunity to advance equity, but practitioners often struggle with how to effectively and strategically communicate about this core value of HIA. An effective approach to communication, including crafting a purposeful plan for the content and presentation of the HIA report and other materials, is fundamental to ensuring that HIAs can impact policies and support change.

This guide intends to aid HIA practitioners in their efforts to communicate about equity as an essential step towards advancing equity through practice.

Link to document

HIA Practitioner Workshop in the U.S.A. in March

SOPHIA's HIA Practitioner Workshop (formerly HIA of the Americas) will take place March 7-8, 2016 at The California Endowment in Oakland, CA. The Workshop is intended for current practitioners of Health Impact Assessment interested in strategic field building. Attendees at the two-day workshop will learn and share ideas through presentations, and further the practice of HIA in small working groups.

Registration is now open through February 1, 2016. Please click here to submit your registration form.

The objectives of this two-day workshop are to:
Build a community of HIA practitioners by offering an intimate forum to network and share ideas and tools that elevate the practice of HIA; and
Promote excellence in HIA by sharing best practices, tackling challenging HIA related issues, and disseminating resources and work products developed by the working groups.

Please visit the SOPHIA website for the draft agenda, more details on registration, location and past workshops. We hope you can join us!

Health impact assessment needs maturity models

Whenever I used to write anything about health impact assessment I started with "HIA it is a new field". That’s no longer the case. People have been grappling with how to make HIAs routine for more than twenty years. This has taken different forms. It’s described as institutionalisation, mandating, capacity-building, integration, harmonisation and even theoretical alignment. People have often conflated quite different HIA activities as the same thing,  complicating things. This led to people talking at cross-purposes.

How to make HIA part of routine practice is really none of these things. It’s about how we get HIA to the next level.

The next level?

What do I mean by this? The next level represents deeper embedding in routine practice. A more sophisticated understanding of when HIA can be useful. A large enough body of practitioners with varying levels of experience.

These challenges apply within countries but also globally.

How do we get from where we are to this next level? We have describe what the current state of practice is (this varies). We also have articulate what our desired future state would be. And then we have to describe what steps lie between.

Maturity models can help us.

Maturity models

Maturity models are quality improvement tools that were first used in information technology. ‘Maturity’ referred to the optimisation of processes, including changes from ad-hoc to formalised arrangements and ongoing quality improvement. This involved describing different levels of maturity across several different domains.

The different domains in a maturity model are usually rated for their maturity:

1. initial - involves individual heroes, is not well documented and hard to replicate
2. repeatable - processes are well enough described or understood that they can be repeated
3. defined - the processes are defined and confirmed
4. managed - the processes are managed in line with agreed metrics
5. optimising - process management includes ongoing optimisation and improvement.

In some cases a sixth level is added.  This involves embedding capability across all processes.

What would HIA maturity models include?

HIA maturity models would enable us to think about which domains of maturity matter. These could include:

• organisational capacity
• workforce
• leadership
• resources and tools
• resource allocation.

I think use of maturity models would enable more sophisticated thinking about capacity building. It would enable discussions to move beyond their historical focus on regulations and workforce. I've attempted to pull together a draft HIA maturity model below.

This model isn't perfect and it won't be applicable in all settings. It will need to be adapted, changed and maybe even started from scratch. I hope maturity models like it will enable a more nuanced way of thinking about the domains of capacity that are required and to focus activity and investment.

In summary

Maturity models  give systems, organisations and HIA practitioners a better framework for understanding the range of capabilities that we need for HIA to flourish. HIA maturity models would identify:

• the domains of HIA capability
• provide a basis for appraising HIA capability, development and performance
• describe the characteristics of different levels of HIA capability
• provide a description of what enhanced capability and practice would involve.

I think maturity models represents a promising area of practical and conceptual development for HIA. I'm interested in what you think.

Short HIA training course: gauging interes

From Marla Orenstein from Habitat Health Impact Consulting:

We are currently trying to gauge the level of interest in having a short HIA training workshop (2-3 days) held in different cities — possibly including yours!  We have developed a very brief survey to help us find out where there might be interest.  If you or anyone from your organization might be interested in a short HIA training workshop, we would really, really appreciate it if you would fill this survey out.  It would also be enormously helpful if you could pass the message along to anyone else who you think might be interested.  The survey takes under 3 minutes to complete.

The survey can be accessed here: https://ardethevans.typeform.com/to/Qinesx

HIA of transport projects for Plaine Commune

Download the report

An English summary of the Plaine Commune HIA of transport projects has been developed. It describes an HIA of three related transport projects in the Saint-Denis area of Paris.

You can download the report here.

APHA summer webinar series about racism's impact on health and disparities in the USA

The recent events in Charleston, South Caroline, Baltimore, Maryland, and Ferguson, Missouri, remind us that stigma, inequalities and civil rights injustices remain in our society today. Unfortunately, skin color plays a large part in how people are viewed, valued and treated. We know that racism, both intentional and unintentional, affects the health and well-being of individuals and communities and stifles the opportunity of many to contribute fully to the future and growth of this nation.

Join the leadership of the American Public Health Association in a summer webinar series about racism's impact on health and disparities. This a four part webinar series.


Register by clicking here.

Naming and Addressing Racism: A Primer

July 21, 2015 | 2 p.m. EDT

Use timeanddate.com to find the time in your timezone.

Shiriki Kumanyika, PhD, MPH, and Camara P. Jones, MD, MPH, PhD 

This kick-off webinar featuring APHA’s executive director, president and president-elect will take a look at some of the nation’s leading health inequities.

APHA President Shiriki Kumanyika will discuss how racism is one of the most challenging tools of social stratification we face when trying to improve the health of the public. She also will reflect on the evidence and research needs related to how racism limits our ability to make America the healthiest nation.

APHA President-Elect Camara Jones will tell the Gardener's Tale and present a framework for understanding racism on three levels. This framework is useful for understanding the basis for race-associated differences in health, designing effective interventions to eliminate those differences and engaging in a national conversation.

Upcoming webinars in this series:

Community Violence Well-Being
August 4, 2015, 2 p.m. EDT

Unequal Treatment: Disparities in Access, Quality and Care
August 18, 2015, 2 p.m. EDT

Racism: The Silent Partner in High School Dropout and Health Disparities
September 1, 2015, 2 p.m. EDT

United Nations Development Program (UNDP) Global Roster of Environmental, Social and Health Expert Consultants

UNDP is establishing a global roster of expert consultants to support implementation of our Social and Environmental Standards (SES), deadline for applications is Friday, August 7:

http://jobs.undp.org/cj_view_job.cfm?cur_job_id=58123


Background

UNDP’s Social and Environmental Standards (SES) underpin our commitment to mainstream social and environmental sustainability in our Programmes and Projects to support sustainable development.

The objectives of the standards are to:
Strengthen the social and environmental outcomes of Programmes and Projects;
Avoid adverse impacts to people and the environment;
Minimize, mitigate, and manage adverse impacts where avoidance is not possible;
Strengthen UNDP and partner capacities for managing social and environmental risks;
Ensure full and effective stakeholder engagement, including through a mechanism to respond to complaints from project-affected people.

The SES are comprised of an Overarching Policy and Principles, Project-Level Standards, and a Policy Delivery Process. The overarching policy and principles at the core of the SES are: (i) human rights-based approach to development programming; (ii) gender equality; and (iii) environmental sustainability.

A key mechanism to ensure these standards are applied is through UNDP’s project-level Social and Environmental Screening Procedure (SESP) which is a requirement for all proposed projects with a budget of $500,000 or more. The objectives of the SESP are to: (a) Integrate the SES Overarching Principles (human rights, gender equality and environmental sustainability); (b) Identify potential social and environmental risks and their significance; (c) Determine the Project's risk category (Low, Moderate, High); and (d) Determine the level of social and environmental assessment and management required to address potential risks and impacts.

UNDP’s SES and SESP came into effect January 1, 2015. The challenge now is to ensure successful implementation and strengthened capacities of staff to apply the standards.

Duties and Responsibilities (if selected to be on the roster and then selected for an assignment

To support implementation of the SES a Roster of Social and Environmental Standards Experts will be established. Experts will need to demonstrate extensive experience in at least one (preferably multiple) of the thematic areas listed below:

• Human Rights (including human rights based approach and human rights impact assessment);
• Gender Equality and Women’s Empowerment (including gender mainstreaming and gender analysis);
• Biodiversity Conservation and Sustainable Natural Resource Management (including mitigation and use of offsets, protected areas, forests, water);
• Climate Change and Disaster Risk Reduction (including climate risk analysis, disaster risk, greenhouse gas emissions);
• Community Health and Safety (including infrastructure safety, health impacts, emergency preparedness);
• Labour Standards (including familiarity with ILO standards, decent work);
• Cultural Heritage (including chance find procedures, physical and intangible cultural resources);
• Displacement and Resettlement (including Resettlement Action Plan, livelihoods);
• Indigenous Peoples (including Free, Prior and Informed Consent, Indigenous Peoples Plans);
• Pollution Prevention and Resource Efficiency (including pollution prevention plans, waste management, hazardous materials);
• Social and Environmental Screening and Assessment (including Environmental and Social Impact Assessment, Strategic Environmental and Social Assessment, Environmental and Social Management Plans).

Relevant experience includes demonstrated familiarity with the relevant UN international legal and normative framework, the application of relevant standards, stakeholder engagement, analytical tools, methods, impact assessment and risk management measures during the planning and implementation of development projects.

The duties and responsibilities detailed below are a representative, but not exhaustive, list of potential activities.

Specific Terms of Reference will dictate the scope of work and the selection of experts from the vetted roster for each of the assignments. Key areas of support and activities will include:

Development of guidance and tools

• Provide inputs in area(s) of expertise to the development of guidance and tools to support implementation of the SES;
• Support the elaboration of case studies;

Capacity development and trainings for staff

• Support the development and delivery of trainings for staff, including webinars, the development of online training content, and support to face-to-face trainings;
• Support the development of learning materials, including case studies and documentation of lessons learned.
• Technical and advisory support related to implementation of the SES
• Review draft SESP reports and related assessments and management plans and provide advice on how to further strengthen the quality.
• Support the conduct of assessments and development of management plans.
• Support implementation and monitoring of management and mitigation activities.
• Institutional arrangements will be agreed if a contract is formalized. The hired consultants will report to, seek approval/acceptance of outputs as specified in the contract.

Duration of the Work: (If selected for roster and then selected for a specific project)

One year initial with possibility of extension up to two additional years subject to satisfactory performance. 

Competencies

• Specific technical expertise in at least one of the SES thematic areas listed above;
• Highly organized with strong analytical and research skills;
• Excellent analytical, writing, advocacy, presentation, and communications skills;
• Ability to prepare succinct, analytical publications and reports;
• Focuses on impact and result for the client and responds positively to critical feedback;
• Demonstrated ability to work in an independent manner.

Required Skills and Experience

Education:

• Masters degree in field related to international development, with specific academic background related to social and environmental sustainability.

Experience:

• At least 10 years of experience related to social and environmental standards and impact assessment in an international development context;
• Experience developing and conducting training related to social and environmental standards;
• Experience or strong familiarity with the work of UNDP and/or other multilateral, bilateral and civil society development partners.
• Familiarity with the UN System, in particular UNDP.

Is there evidence that walking groups have health benefits? A systematic review and meta-analysis

Is there evidence that walking groups have health benefits? A systematic review and meta-analysis

Sarah Hanson, Andy Jones

9 November 2014

Regular physical activity positively impacts health potentially offering similar effects to some drug interventions in terms of mortality benefits. Indeed, it has been suggested as an alternative or adjunct to conventional drug therapy. Walking at a pace of 3–5 m/h (5–8 km/h) expends sufficient energy to be classified as moderate intensity2 and is an easy and accessible way of meeting physical activity recommendations.

Systematic reviews and meta-analyses have shown walking to have various health benefits including:

• positive effects on fitness
• fatness and resting blood pressure
• blood pressure control
• weight loss
• depression
• cardiovascular disease risk prevention.

ABSTRACT

Objective

To assess the health benefits of outdoor walking groups.

Design

Systematic review and meta-analysis of walking group interventions examining differences in commonly used physiological, psychological and well-being outcomes between baseline and intervention end.

Data sources

Seven electronic databases, clinical trial registers, grey literature and reference lists in English language up to November 2013.

Eligibility criteria

Adults, group walking outdoors with outcomes directly attributable to the walking intervention.

Results

Forty-two studies were identified involving 1843 participants. There is evidence that walking groups have wide-ranging health benefits. Meta-analysis showed statistically significant reductions in mean difference for systolic blood pressure −3.72 mm Hg (−5.28 to −2.17) and diastolic blood pressure −3.14 mm Hg (−4.15 to −2.13); resting heart rate −2.88 bpm (−4.13 to −1.64); body fat −1.31% (−2.10 to −0.52), body mass index −0.71 kg/m2 (−1.19 to −0.23), total cholesterol −0.11 mmol/L (−0.22 to −0.01) and statistically significant mean increases in VO2max of 2.66 mL/kg/min (1.67 3.65), the SF-36 (physical functioning) score 6.02 (0.51 to 11.53) and a 6 min walk time of 79.6 m (53.37–105.84).

A standardised mean difference showed a reduction in depression scores with an effect size of −0.67 (−0.97 to −0.38). The evidence was less clear for other

outcomes such as waist circumference fasting glucose, SF-36 (mental health) and serum lipids such as highdensity lipids. There were no notable adverse side effects reported in any of the studies.

Conclusions

Walking groups are effective and safe with good adherence and wide-ranging health benefits. They could be a promising intervention as an adjunct to other healthcare or as a proactive health-promoting activity.

Open Access

Original Source BJSM