Impacts of changes in environmental exposures and health behaviours due to the COVID-19 pandemic on cardiovascular and mental health: A comparison of Barcelona, Vienna, and Stockholm

Abstract

Responses to COVID-19 altered environmental exposures and health behaviours associated with non-communicable diseases. We aimed to (1) quantify changes in nitrogen dioxide (NO₂), noise, physical activity, and greenspace visits associated with COVID-19 policies in the spring of 2020 in Barcelona (Spain), Vienna (Austria), and Stockholm (Sweden), and (2) estimated the number of additional and prevented diagnoses of myocardial infarction (MI), stroke, depression, and anxiety based on these changes. We calculated differences in NO₂, noise, physical activity, and greenspace visits between pre-pandemic (baseline) and pandemic (counterfactual) levels. With two counterfactual scenarios, we distinguished between Acute Period (March 15th - April 26th, 2020) and Deconfinement Period (May 2nd - June 30th^, 2020) assuming counterfactual scenarios were extended for 12 months. Relative risks for each exposure difference were estimated with exposure-risk functions. In the Acute Period, reductions in NO₂ (range of change from -16.9 μg/m³ to -1.1 μg/m³), noise (from -5 dB(A) to -2 dB(A)), physical activity (from -659 MET*min/wk to -183 MET*min/wk) and greenspace visits (from -20.2 h/m to 1.1 h/m) were largest in Barcelona and smallest in Stockholm. In the Deconfinement Period, NO₂ (from -13.9 μg/m³ to -3.1 μg/m³), noise (from -3 dB(A) to -1 dB(A)), and physical activity levels (from -524 MET*min/wk to -83 MET*min/wk) remained below pre-pandemic levels in all cities. Greatest impacts were caused by physical activity reductions. If physical activity levels in Barcelona remained at Acute Period levels, increases in annual diagnoses for MI (mean: 572 (95% CI: 224, 943)), stroke (585 (6, 1156)), depression (7903 (5202, 10,936)), and anxiety (16,677 (926, 27,002)) would be anticipated. To decrease cardiovascular and mental health impacts, reductions in NO₂ and noise from the first COVID-19 surge should be sustained, but without reducing physical activity. Focusing on cities' connectivity that promotes active transportation and reduces motor vehicle use assists in achieving this goal.

Keywords: Air pollution; Cardiovascular disease; Greenspace; Mental disorders; Noise; Physical activity.

Graphical abstract

Fig. 1

Conceptual framework of the Urban and Transport Planning Health Impact Assessment Tool (UTOPHIA) (1) Pre-Pandemic Exposure setting (averages based on data from 2016/2017 to 2019); (2) Acute Period (March 15th^, 2020–April 26th^, 2020); (3) Deconfinement Period (May 2nd^, 2020–June 30th^, 2020), (4a) Exposure difference between pre-pandemic exposure and the Acute Period, (4 b) exposure difference between pre-pandemic exposure and the Deconfinement Period, (5) exposure response function (ERF) to quantify the association between exposure and incidence rate, (6) relative risk (RR) corresponding to the exposure difference, (7) population attributable fraction (PAF) corresponding to the exposure difference; (8) preventable cardiovascular disease (CVD) and mental disorder (MD) diagnoses. – Figure adapted after Mueller et al. (2017b).

Fig. 2

Cumulative prevented and additional diagnoses per 1000 adult citizens by city and environmental exposure or health behaviour. Abbreviations: MI: myocardial infarction.

Fig. 3

Conceptual framework for the interplay of cardiovascular disease and mental health disorders with environmental exposures and health behaviours - An overview of potential urban planning solutions that shift underlying mechanisms to improve cardiovascular and mental health.