Difference between revisions of "WHO:Be mobile, active - and safe!"

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Physical activity improves well-being: its benefits to physical and mental health are well-documented at all ages, and it helps prevent overweight and obesity, type II diabetes, cardiovascular disease, hypertension and some forms of cancer.
Physical activity improves well-being: its benefits to physical and mental health are well-documented at all ages, and it helps prevent overweight and obesity, type II diabetes, cardiovascular disease, hypertension and some forms of cancer.
[[file:youngdrownfallfirepoisondeaths.png|thumb|250px|Standardized death rates from drowning, poisoning, falls and fires,1−19 years, 2006 and earlier<ref name="who"/>
[[file:youngdrownfallfirepoisondeaths.png|thumb|250px|Standardized death rates from drowning, poisoning, falls and fires,1−19 years, 2006 and earlier<ref name="who"/>]]
'''Some options to reduce injuries to children from four different hazards'''<ref name="who"/>
'''Some options to reduce injuries to children from four different hazards'''<ref name="who"/>

Revision as of 10:45, 7 May 2012

This text is taken from the WHO report "Health and Environment in Europe: Progress Assessment", 2010, ISBN 978 92 890 4198 0. [2]

Regional priority goal II: We aim to prevent and substantially reduce health consequences from accidents and injuries and pursue a decrease in morbidity from lack of adequate physical activity, by promoting safe, secure and supportive human settlements for all children.[1]

Key messages

  • Unintentional injuries are a leading cause of death in young people aged 0–19 years, with road traffic injuries contributing the largest burden followed by injuries occurring in the home and leisure settings. Inequalities between countries are extreme. A substantial reduction in traffic-related deaths over the last two decades shows that these injuries and deaths are preventable.
  • There is wide variability in the national proportions of overweight and obese children, ranging from 3% to more than 30% in 11–15-year-olds. The problem appears to be worsening in many countries in recent years.
  • Asubstantial proportion (often 40–50% or more) of 11-year-olds in all countries in the Region do not engage in enough physical activity; the proportion is even higher among 13-and 15-year-olds.
  • There is growing evidence that well-designed built environments and public green spaces enhance physical activity patterns and reduce the risk of injuries.
  • Coordinated, intersectoral injury prevention and health promotion policies are required to reduce health burdens from unintentional injuries, low physical activity levels and obesity.
  • Tailored approaches are required for specific groups of citizens to benefit from the full potential of public places and networks to exercise and be physically active, and to be protected from safety threats in the urban, transport, home and leisure environments.[1]

Injuries and physical inactivity: public health importance

Unintentional injuries

Unintentional injuries cause 42 000 deaths in children and adolescents aged 0–19 years in the Region each year. Road traffic injuries are the leading cause of death, while deaths from drowning, poisoning, falls and fires are also substantial.

Boys suffer three out of four deaths from unintentional injuries in the Region, reflecting differences in exposure patterns compared to girls, particularly in relation to road traffic injuries. Five out of six of all deaths from unintentional injuries occur in poorer countries. Reducing child mortality rates from unintentional injuries across the Region to the lowest national rates would prevent around three out of four deaths.

The relative importance of the causes of injury changes as a child grows through adolescence to young adulthood owing to factors including curiosity, risk behaviour and awareness, coping skills, ability to follow instructions, mobility and the extent of supervision.[1]

Deaths from unintentional injuries by cause, 0-19 years, WHO European Region, 2004 [1]
Top three causes of death (total deaths) due to unintentional injury in groups aged 0–4, 5–14 and 15–29 years, WHO European Region[1]

Road traffic injuries – a leading cause of death

Overall, road traffic injuries are the third leading cause of death in the Region among young people aged 0–24 years, which includes young and inexperienced drivers, causing about 100 deaths daily in this age group. Approximately four fifths of these deaths occur in the group aged 15–24 years, making them a major public health challenge for adolescents and young adults.

Deaths from road traffic injuries are not evenly distributed. Geographically, the highest rates occur in the north-eastern and eastern parts of the Region. Among EU member states, those in the north have lower mortality than those in the south. It is notable that countries with the highest death rates (Kazakhstan, Lithuania and the Russian Federation) have rates seven to eight times higher than those with the lowest rates. Deaths, however, are only the tip of the iceberg; on average, there are 35 injuries for each fatality, the consequences of which persist for many years. Furthermore, evidence shows that up to 33% of children involved in road traffic injuries develop post-traumatic stress disorder.

Death and injury rates from road traffic injuries depend on both driving-related factors, such as the number of vehicles, driving style and risk perception, the existence of legislation and the strength of its enforcement, road design and maintenance, and factors unrelated to driving, including emergency response services, mobility options and socioeconomic conditions. The overall death rates need, therefore, to be considered within this wider context. When this is done, it strongly modifies the ranking of countries. Kyrgyzstan, for example, reports the second lowest injury rate from road traffic injuries per 100 000 population but the highest injury rate per 100 000 motor vehicles. Furthermore, for many countries the data on death and injury rates do not correlate: the Russian Federation, which has the highest death rate related to road traffic injuries in young people in the Region reports a relatively modest road traffic injury rate in the same group. Variations in reporting patterns, differences in definitions, and inconsistencies are likely to contribute to at least some of the discrepancies that exist between as well as within national data.[1]

Standardized death rates (three-year average) for road traffic injuries, 0-24 years[1]
Standardized road traffic injury rates, and road traffic injuries per motor vehicle, 0−24 years, 2003/2004[1]

Road traffic injuries are not all the same. Although cars are the most frequent mode of transport involved in all countries, motorized two-wheelers, cyclists and pedestrians are vulnerable road users who have the highest crash fatality rate and deserve special attention. Children under 10 years of age are disproportionately represented in road crashes as pedestrians, and pedestrian deaths tend to be higher in countries with lower per capita gross national income. There is also social inequity, as children in deprived areas may have a four times higher risk for pedestrian injuries than children in more affluent areas. Some 80% of those aged 0–24 years involved in vehicle crashes are male.

Overall death rates from road traffic injuries in the Region have declined by a third since the early 1990s, although this masks the fact that available data show that rates within the newly independent states have actually risen in recent years. Still, the overall reduction demonstrates that it is possible to reduce transport-related mortality and, with a large proportion of all road traffic injuries being attributable to unsafe road environments, that interventions focusing on the road environment can contribute significantly to this reduction. Separating different types of road user through the use of bicycle lanes, pedestrian walkways, raised crossings and so on, is an important infrastructural intervention. Other important risk factors that need to be tackled include speed, alcohol, and not using protective equipment such as seat belts, child car restraints and motorcycle helmets. Road traffic injuries are a consequence of many different factors so successful programmes will require intersectoral initiatives and should receive close attention at all levels of society. In addition to the individual health burden, the economic costs of road traffic injuries to society are also sizeable: estimates suggest that they cost about 2% of the gross domestic product. The costs of road traffic fatalities among those aged 0–24 years in the Region are an estimated US$ 38 billion.[1]

Mortality rates from road traffic injuries per 100 000 population, newly independent states and EU27 (All member states of the European Union since 2007), 1980−2006[1]

Unsafe homes and neighbourhoods

Some of the major causes of death from unintentional injury involving children and adolescents in the Region are drowning, poisoning, falls and fires. Death rates from all four causes have declined since 1995, but current rates are still high in many countries and vary greatly across the Region. Death rates in children and adolescents are generally lowest in western Europe and highest in some eastern European countries and newly independent states. This inter-country inequality in child injury mortality is extremely pronounced. Countries with the highest and lowest rates differ:

  • 20-fold in terms of the risk of drowning,
  • 30-fold for poisoning,
  • 85-fold from fires and
  • 22-fold for falls.

The relative contribution to all deaths from these four causes in the group aged 1–19 years also differs widely between countries.

Within unsafe environments, a variety of factors can lead to many different injuries, and the appropriate measures to protect children vary accordingly (Table 2).

Socioeconomic factors also play a key role in injuries to children. For example, poorer households are more likely to live in or near unsafe environments and to resort to (or be forced by circumstances into) unsafe behaviour such as poor supervision of children.

Deaths from these four hazards alone again only tell part of the story. For each child’s death between 0–14 years caused by unintentional injuries at home or at leisure, there are an estimated 160 hospital admissions and 2000 visits to emergency departments.These incidents may have long-term physical and psychological consequences.[1]

Standardized death rates from drowning, falls, fire and poisoning, WHO European Region, 1995−2007[1]

Excess weight and obesity: an epidemic

Excess weight and obesity in young people are major risk factors for chronic disease and are associated with an increased risk of adult obesity and premature mortality. Accordingly, WHO already recognizes that excess weight and obesity in childhood have reached epidemic proportions in most industrialized countries.

A major concern is that the prevalence of overweight and obese children and adolescents continued to increase in more than half of the countries from 2001 to 2005. Only three countries (Austria, France and the United Kingdom (England)) showed a fall in the prevalence during this period for both boys and girls.

There are wide variations in the prevalence of obese and overweight children among countries in the Region, ranging from 4% to over 30% of 11–15-year-olds being overweight. Most countries show a greater proportion of overweight boys than girls. However, there is little evidence of significant age differences or of any clear geographical pattern.

These trends reveal that despite many international and national efforts, the anticipated positive consequences have not become apparent. Further dedication and innovation may, therefore, be required. An increasing incidence of obesity-related chronic diseases in adolescents, such as type II diabetes and hypertension, foretell a larger burden of disease if no appropriate action is taken.[1]

Physical activity: getting active

Physical activity improves well-being: its benefits to physical and mental health are well-documented at all ages, and it helps prevent overweight and obesity, type II diabetes, cardiovascular disease, hypertension and some forms of cancer.

Standardized death rates from drowning, poisoning, falls and fires,1−19 years, 2006 and earlier[1]

Some options to reduce injuries to children from four different hazards[1]

Drowning Poisoning Fires Falls
Cover water hazards Ensure chlind-resistant packaging Install fire alarms Install window guards
Remove water hazards Store toxins safely Install thermostats Modify unsafe products
Fence water hazards Create poinson control centers Apply standards for cigarette lighters Apply playground standards
Prevalence of overweight (including obese) 13-year-olds in 31 countries and areas of the WHO European Region, 2001 and 2005[1]

How active children are tends to be influenced by demographic factors (age and socioeconomic status), psychological factors (perceived competence and enjoyment), social factors (encouragement from parents or peers and cultural attitudes), the educational environment (the number of hours of lessons and home-work), and the physical environment (the availability of safe opportunities to be active, or walking and cycling as reasonable mobility options). Physical education in day care centres and schools is – either as curricular or extra-curricular activity – important as well.

Information on physical activity in the Region is not yet fully standardized and available for all countries. In children and adolescents, one of the most comprehensive sources of information is provided by the Health Behaviour in School-aged Children (HBSC) study, which documents the proportion of children having at least 60 minutes of moderate-to-vigorous physical activity at least five days a week. This study was conducted in 2001/2002 and repeated in 2005/2006.

Although the study was based on self-reported activity (as opposed to objective measurement), it revealed that in all countries a considerable proportion of children and adolescents do not reach the recommended levels of physical activity. Among 11-year-old boys, only 38% achieved the recommended levels of activity in the Russian Federation and 80% in Ireland in 2005/2006. For girls of the same age, these rates ranged from 24% in Portugal to 71% in Finland.

Sufficiently physically active 11-year-olds, selected countries of the WHO European Region, 2001/2002 and 2005/2006 (%)[1]

The study also revealed that physical activity levels are generally less frequent among girls than boys and that the percentage of sufficiently active children decreases with age in both sexes. However, a positive indication is that in 2005/2006, recorded physical activity was noticeably more frequent in all age groups for both boys and girls compared to 2001/2002. Further monitoring will follow this positive development.[1]

Average percentage of physically active boys and girls in Europe, 2001 and 2005[1]

Potential health benefits from mitigating climate change

Strategies aimed at mitigating climate change are anticipated to have numerous implications for human health, including effects on unintentional injuries, physical activity and obesity. In particular, policy choices in the transport sector are likely to have a major influence on healthy mobility and physical activity. Among other effects, future transport policies may influence the type and number of vehicles on the road and, correspondingly, support and promote active travel opportunities that do not cause CO2 emissions. These changing patterns may, in turn, affect levels of physical activity as well as the frequency and severity of road traffic injuries. Similarly, urban development plans that promote mixed land use and compact cities can reduce the need for long-distance travelling and dependence on cars, opening up opportunities for short trips to be undertaken on foot, by bicycle or on public transport.

A recent paper comparing future (2030) health impacts of alternative transport-related climate mitigation strategies with a baseline “business as usual” scenario in London and Delhi found that strategies incorporating steps to increase active travel were beneficial in both cities. The number of DALYs in the two cities were reduced through enhanced physical activity (by around 7000 DALYs per million people per year in each city) compared to the baseline scenario (17). A policy that simply reduced motor vehicle emissions without fostering active transport did not alter levels of physical activity.

In terms of road traffic injuries, the results were mixed: Delhi showed a considerable reduction in the burden from them (by around 3500 DALYs per million people per year), while the burden in London increased somewhat (by 500 DALYs per million people per year), due to the higher number of vulnerable pedestrians and cyclists. Importantly, this evidence points to an overall public health benefit that greatly overcomes the possible increase in road traffic injuries, which in turn can be controlled through effective preventive measures.

Climate change mitigation may also affect other environmental health concerns discussed here. For example, novel rainfall and flooding patterns could have important local impacts on the rates of injuries and drowning. Taken all together, the adoption of climate mitigation policies that act at the level of urban and transport planning offers an important opportunity to improve environmental safety and to gain the corresponding co-benefits for health.[1]

Injuries, health and safety: policy analysis

The saying “injuries are no accidents” may seem obvious today, but for a long time, injuries were regarded either as inescapable occurrences or as the consequences of human carelessness. This situation has, however, changed during the last decade, which is obvious when the increase in research on injury prevention since the start of the 1990s is taken into account. Another recent change in perception concerns physical activity. In addition to psychological or social barriers to physical activity, in recent years there has been a growing realization that environmental factors are also important. Research shows, for example, that neighbourhood characteristics of the built environment (such as the existence of sidewalks and walking and jogging trails, and perceived safety from crime) are associated with physical activity. Purpose-built bicycle routes or lanes reduce the risk of crashes and injuries compared to cycling on the road with traffic. This shows that environmental changes can both reduce injuries and increase the levels of physical activity in a community.

Three topics from regional priority goal II were selected for policy screening in the policy survey: road traffic injuries, unintentional injuries (excluding road traffic) and physical activity. A total of 33 Member States replied, although responses did not always include all topics. This assessment focuses on unintentional injuries (excluding road traffic injuries) and physical activity. Road traffic injuries have been extensively reviewed elsewhere in a recent WHO report.

Policy profiles for unintentional injuries unrelated to traffic and physical activity covering the six aspects (policy development, implementation and enforcement, accountability for health, health sector involvement, equity considerations and provision of information to public) reveal similar and symmetrical patterns between country groupings. The main exception is the implementation and enforcement aspect of the physical activity policy profile, which ranges from 0% to 70% and thereby indicates that different groups of countries show very different degrees of implementation and enforcement of policy. Implementation and enforcement are also recognized as the weakest dimension for both physical activity policies as well as injury-related policies: only for this policy dimension do the values drop below 20%. Similarly, for both health issues policy development is not very strong. In comparison, the involvement of the health sector is quite strong in most country groupings, with EurG-C countries reporting the lowest involvement levels in both cases.[1]

Policy profiles for unintentional injuries unrelated to traffic and physical activity, by country grouping[1]

Public governance

Objectives, scope and type of policy measures

As both physical activity and injury prevention are public health challenges that have become more important in recent years, they may be relatively novel to policy-makers. This is one possible explanation for why policy development and implementation and enforcement in regional priority goal II shows clearly lower scores compared to, for example, the first regional priority goal, or outdoor air quality discussed in regional priority goal III, which are longstanding environmental health concerns for which polices have been developed and applied for many decades. The relatively low scores may also, however, be due to difficulties in regulating leisure time injuries or physical exercise by laws or binding agreements compared, for example, to health and safety practices at the workplace. Moreover, it is possible that regional or local authorities, not the national governments who received the questionnaire, are responsible for tackling this issue. Still, a strong national policy framework on which to base local action would seem to be of equal importance.

Yet another possible explanation for the low level of policy development is that the responsibility for physical activity may have fallen between two chairs, with no actors seeing themselves as owners of the issue. The low scores on policy development and implementation and enforcement may indicate that there are only a few regulations in these areas. At the same time, the responses to the survey suggest that in several countries the health sector may not be in a leading position within the government when it comes to the promotion of physical activity and prevention of injury: the scores for health sector involvement are relatively high but, considering the issue and its impact on health, they should be even higher since the health sector should represent the driving force on this issue.

Compared to, for example, regional priority goals I and III, there are relatively high scores on equity considerations, which might indicate that the regional priority goal II policy measures (such as information, education and promotion of health and safety) focus on specific settings or exposed population groups that are most at risk. More detailed policy analysis is, however, needed to identify how, and to what extent, the still evident equity gaps can be reduced within the existing policy context.[1]

All country groupings pay attention to unintentional poisoning but emphases vary when it comes to unintentional injury during leisure activities (see, for example, the low level of policy measures in EurG-C and EurG-D countries) and injuries at home (the low level of policy measures in the EurG-B and EurG-C countries). The relatively low overall scores for home and leisure injuries are of concern, as injuries in those settings are a major burden in Europe. It is estimated that 78 000 deaths were caused by home and leisure injuries in 2005, with the eastern part of Europe (especially the Baltic countries) experiencing the highest mortality rates.

Looking in more detail at the national policy measures applied to prevent unintentional injuries and promote physical activity, some of the commonest measures under policies on injury prevention deal with children’s safety. These measures include, for example, standards for playground equipment and water safety education (such as swimming lessons) in schools. As for injuries related to burns, several countries across the Region have building code requirements for, for example, smoke detectors or emergency fire staircases in place. Nevertheless, there is still scope to introduce relatively simple but less frequently used measures, such as pre-set temperatures for water taps. Product safety measures also generally seem to be well reflected, with the frequent application of warning labels and material and standards for design of playground equipment and landing surfaces. Further promotion would be needed to require mandatory first aid appointees in public buildings and companies in more countries.

Types of unintentional injury covered by policy measures, by country grouping[1]

Where policy measure for promoting physical activity are concerned, many countries try to encourage the building of networks for cycling and walking either through a separation of paths for walking and cycling (EurG-A and EurG-C countries) or the development of urban transport networks or streets equipped with pedestrian and bicycle lanes (EurG-B and EurG-C countries). Countries in EurG-D mainly focus on the accessibility and quality of the available open and public spaces to promote activity. Solutions associated with the transport system do not play a major role in these countries.[1]

Objectives of policy measures on physical activity, by country grouping[1]

Compared to regional priority goal I and the outdoor air dimension in regional priority goal III, policy responses are less likely to involve legislation and more likely to use action programmes, although legislative solutions are more likely to be used to prevent unintentional injuries. Action plans and programmes are typically used most frequently to promote physical activity, which is not surprising as promotion is seen as a key element in increasing the health benefits related to physically active lifestyles.

Types of policy instrument used for tackling unintentional injuries and promoting physical activity[1]

The scarcity of legally binding policy documents (and commitments) was also noted in a recent review of physical activity policies in Europe. Only 3 out of 49 documents included in that analysis were identified as legally binding. One possible explanation for the small number of such binding commitments is that when it comes to injuries and physical activity, the focus has traditionally been on measures to alter behaviour, such as information campaigns on how to be safe in the traffic or at home, or why physical activity is important. As noted above, however, the importance of environmental determinants for both injuries and physical activity has been highlighted in recent years. There is still room for improvement by developing policy measures focusing on the provision of adequate and supportive settings for mobility and activity.[1]

Impact of international policy processes

Another partial explanation of differences between regional priority goals I, III and IV versus regional priority goal II is the absence of legally binding EU directives or laws, although there are a number of international initiatives which should influence national strategies. These include WHO’s Global strategy on diet, physical activity and health, the European strategy for the prevention and control of non-communicable diseases and the European Charter on Counteracting Obesity. The EU Council Recommendation on the prevention of injury and promotion of safety, adopted in 2007, and the WHO European Region resolution EUR/RC55/R9 in 2005 on the prevention of injuries have both provided a policy framework for action in Europe. At a global level, World Health Assembly resolution WHA57.10 on road safety and health and United Nations resolution 60.5 on improving road safety have both provided a stimulus for policy development. A compilation of consensus documents on health promotion, which among other things concern physical activity, has recently been published. In addition, online inventories have been established by the Regional Office that provide access to national policies on physical activity promotion and injury prevention.[1]

Healthy public policy

There is a great variance among the scores of the country groupings for policy accountability for health and health sector involvement. The lower scores for health accountability in EurG-A and EurG-B countries are of especial concern. Since several countries within these groupings report a high prevalence of childhood obesity and overweight, there is a definite need to improve the accountability of the national policy frameworks for health consequences.

Policy evaluation and health accountability

Overall, every grouping (with the exception of EurG-C) reports having more monitoring and data collection systems in place for unintentional injuries than for physical activity. In EurG-A countries there is a higher emphasis on data collection than reporting, whereas in the EurG-D grouping a higher percentage of countries use periodic reports to review policy obligations and fewer report having a monitoring system in place for physical activity (Fig. 27). Without systematic monitoring, it is difficult to determine the effectiveness of periodic reports in these countries. On the other hand, countries with effective monitoring systems in place should focus more on using the data collected in these periodic reports.[1]

Monitoring systems and reporting practices on unintentional injuries and physical activity, by country grouping[1]

Health sector involvement in intersectoral policy action

EurG-D and EurG-B countries report high levels of health sector involvement in policies on unintentional injuries which could be related to the large number of deaths resulting from drowning, falls, fire and poisoning they reported. As for physical activity, EurG-A countries score lower for health sector involvement compared to other groupings. As noted elsewhere, however, the health sector may not have the means or mandate to change this situation, other than to raise awareness and create demands for solutions on injury prevention and physical activity.

Equity considerations

The burden of unintentional injuries, excluding from road traffic, is very unevenly distributed among countries and shows a clear social gradient. This is especially true among younger people (children and adolescents in particular) and people in low- and middle-income countries, for whom injuries as a cause of death and disability are increasing. This is in sharp contrast to downward trends in fatal injuries in countries with higher incomes. The clear need to address specific population groups with specific measures could be a potential reason for the quite good performance (compared to other regional priority goals) on the equity consideration dimension, as it may indicate that many countries have adopted policy measures and campaigns that focus on identified target groups. Only more detailed analysis can reveal to what extent such equity dimensions guide the development of policy and how effective they are in reducing inequities.[1]

Transparency and communication

The provision of information is generally strong. This is the traditional approach for reducing unintentional injury and increasing physical activity, but information provision, by itself, generally does not motivate people to exercise more or change a risk-taking form of behaviour. Other measures, such as building local facilities for exercise, or safe areas separate from traffic, are of equal importance here. An information strategy needs to be combined with other measures such as neighbourhood programmes, legislation and regulations.[1]

Overall progress

Overall, death rates from road traffic injuries have been falling consistently in the Region since the early 1990s, as have rates for the other leading causes of unintentional injuries. This illustrates a central message of this chapter, which is that unintentional injuries are preventable. The preventability of unintentional injuries highlights the unacceptability of the high, and sometimes even rising, rates still found in many countries.

Results from the Health Behaviour in School-aged Children study 2005/2006 show that, compared to 2001/2002, the proportion of young people engaging in moderate to vigorous physical activity generally increased in all three age groups examined (those aged 11, 13 and 15 years). It is not certain that this trend will continue, but the data do suggest that efforts to encourage physical activity can be successful. Now a central challenge is to figure out how to sustain activity as children get older. Trends in obesity are less promising and the impact of increased physical activity levels does not seem to be well-reflected in these figures. From 2001 to 2005, the proportion of overweight and obese young people increased in many countries for both boys and girls; only in three did it decrease.

Together, unintentional injuries, physical inactivity and obesity contribute significantly to the overall health burden in young people in the Region. These burdens are largely preventable but require sustained and integrated efforts in all countries across the health and non-health sectors aimed at improving the safety of home and leisure environments. Ensuring road safety has the health benefit of reducing death and injury while also promoting physical activity with its contribution to the prevention of obesity. Broader gains include a contribution towards the mitigation of climate change by encouraging alternative forms of transport than motor vehicles.

Both unintentional injuries and physical activity are increasingly seen as a public health issue, that is, as something that both policy-makers and communities could, and should, act on. This is manifested in the number of national action plans. There are also fairly good systems in place to follow both the incidence of injuries (although these mostly arise from road traffic incidents) and the number of overweight people in European countries. The significant challenge now is to ensure that action plans or government regulations are actually implemented and followed up, so that it can be determined if they work as intended or if adjustments are needed.[1]

See also


  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 1.31 1.32 1.33 WHO Health and Environment in Europe: Progress Assessment, 2010, ISBN 978 92 890 4198 0[1]
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