A large amount of research on the impact of major sports events on host populations is available, 8 but this body of research has not been systematically brought together to allow decision makers to make informed judgments on the basis of the known effects and the known areas of uncertainty. 9 The aim of this systematic review was to assess the impact of major sporting events (1978-2008) on the health, and the determinants of health, of the host population.

Detailed theories of how the legacy of hosting the games might influence health were outlined in the Department of Health’s recent review of the potential physical activity and health legacy from the London 2012 Olympic Games and Paralympic Games, 6 and in the Scottish Government’s 2014 Commonwealth Games legacy consultation document. 3 The likelihood of benefits arising from major sports events and the relative cost has been re-examined since, however, and the previous Olympics minister for the United Kingdom, Tessa Jowell, has said, “Had we known what we know now, would we have bid for the Olympics? Almost certainly not.” 7

In 2012 the Olympic Games and the Paralympic Games will take place in London, and in 2014 the Commonwealth Games will be hosted by Glasgow. A major consideration in bidding to host the events in London and Glasgow was the potential for the games to generate a wide range of benefits for the population of the host city. 1 2 3 4 Such purported benefits—collectively termed the “legacy”—include improvements in employment levels, the economy, housing, national and local pride, the environment, and sports provision. These outcomes represent key socioeconomic determinants of health, 5 which suggests that the investment has the potential to improve health.

The data were tabulated with an indication of study quality and grouped into nine broad categories according to outcome studied: health; recreation; transport and environment; crime, housing, and demography; volunteers; culture; economics; business; and tourism (tables 1 ⇓ and 2 ⇓ ). Where there were multiple studies with similar outcome measures, the data were synthesised narratively using Economic and Social Research Council guidelines. 15 Synthesis was possible for some outcomes relating to economic growth, employment, tourism and transport. Where there were studies of varying quality, greater emphasis was put on the results of the better quality studies. A range of other diverse outcomes were reported that were not amenable to synthesis; these outcomes have been summarised narratively. The available data were not amenable to formal testing for bias across studies.

A modified version of the Health Development Agency guidelines was used to classify the level of evidence reported in each quantitative study (ranging from 1++ for the highest quality evidence to 4 for evidence based on expert opinion; web table E). 14 The assignment of each level was on the basis of the design of the study and the risk of confounding, bias, or chance influencing the results, as determined by the critical appraisal. Those studies meeting all the critical appraisal criteria were classified as “high quality,” and those meeting the majority of criteria and with a low risk of selection bias (criterion 2 in web table B) were defined as “well conducted.”

All retrieved studies were critically appraised independently by two reviewers. Disagreements were resolved by discussion between reviewers. The quality of all the included studies was assessed using a modified version of the Hamilton quality assessment tool (web table B). 12 Models that assessed economic impact were appraised with additional questions recommended by experts, because no relevant critical appraisal framework could be identified (web table C). Some economic studies used only real time data rather than a mix of real time and estimated data. Variations in data characteristics were part of the critical appraisal tool but were not reflected adequately in the overall grading, so an indication of the studies that used only real time data is provided in the synthesis. An additional set of appraisal questions based on the approach outlined by Dixon-Woods and colleagues was used for qualitative studies (web table D). 13

Two reviewers independently screened all references identified by the searches before duplicates were removed. Studies that were identified as potentially relevant were then retrieved where possible and independently screened for relevance.

We included outcomes relating to health, wellbeing, quality of life, health service use, and physical activity or functioning, and any measures of the socioeconomic determinants of health as described by Dahlgren and Whitehead, 5 including access to services and transport, environment, crime, housing, demography, and cultural and economic outcomes. Studies exclusively investigating the impacts on visitors, athletes, or spectators; the host population’s support for the event; the non-host population’s opinions about the host area; media portrayals of the event; and economic impacts by using exclusively estimated data were excluded. Studies that used a mix of real and estimated data were included. Commentaries that did not present original data or analysis were not included in the review. Simple lists of construction activity related to events (for example, new stadia) were not included, although studies describing the impact of construction on any of the determinants of health (for example, access to facilities or economic growth) were included.

We included studies of any design that had investigated the impact on the host population of any “one off,” international, multi-sport event focused on a single city or area that took place between January 1978 and January 2008. We did not include earlier events because of the increasing focus by host cities on the potential for legacy—rather than national showcasing—after 1978. 11

The search terms we used are detailed in web table A. The reference lists and bibliographies of all the included articles and reviews were searched by hand. A request for relevant studies was distributed using the International Society for Urban Health newsletter and UK and international email lists for health impact assessments.

An extensive search of the “grey literature” was conducted between April 2008 and October 2008 using the following resources: BUBL; Centre for Education in the Built Environment (CEBE); Chartered Institute of Housing (CHI); Copac National, Academic, and Specialist Library Catalogue; Economic and Social Research Council (ESRC) Society Today; Google; IDOX information services; Index to Theses in Great Britain and Ireland; US Department of Housing and Urban Development (HUD); Intute; Proquest Dissertations and Theses database; Royal Town Planning Institute; Sapling.info; Scirus; System for Information on Grey Literature in Europe (SIGLE); Transportation Research Information Service (TRIS); Urban Age; and WorldCat. There was no restriction on the publication date or language.

During February and March 2008, we searched without language restrictions the following sources for articles published between 1978 and 2008: Applied Social Science Index and Abstracts (ASSIA); British Humanities Index (BHI); Cochrane database of systematic reviews; Econlit database; Embase; Education Resources Information Center (ERIC) database; Health Management Information Consortium (HMIC) database; International Bibliography of the Social Sciences (IBSS); Medline; PreMedline; PsycINFO; Sociological Abstracts; Sportdiscus; Web of Knowledge; and Worldwide Political Science Abstracts.

Results

Fifty four studies met the review criteria and were included in our analysis, 25 of which were obtained from the grey literature (figure⇓). Thirty four potentially relevant studies were unobtainable (web extra 1). No systematic reviews were identified. The quality of the included studies was low and characterised by a high risk of bias: 69% of studies used a repeat cross-sectional design and 85% of quantitative studies were assessed as being below level 2+ on the Health Development Agency scale for appraisal of study quality, often because of a lack of comparison group. The level of evidence of the included individual quantitative studies was either 2+ (n=7) or 2− (n=41), whereas three of the studies from the grey literature were level 2+ and three were qualitative. A summary of the reported impacts is presented in tables 1⇑ and 2⇑, with more detailed data available in web table F.

Results of the literature search

Health impacts Only one study included assessment of a direct health impact (table 1⇑).16 Shin and colleagues used a multivariate model to analyse the trends in suicide rates in Seoul, South Korea, during the 1988 Olympic Games (level 2+). They reported no change in the suicide rate. During the 2002 Asian Games in Busan, South Korea, cars were restricted from entering the city on certain days by using car registration plate numbers as a rationing tool. One study (level 2+) reported that paediatric hospital admissions for asthma declined in the three weeks after the Busan event compared with during the games period and the three weeks before the games (relative risk (RR) 0.73, 95% confidence interval (CI) 0.49 to 1.11).17 This finding contrasted with the same period in the following year, in which hospital admissions increased compared with three weeks before and three weeks after (RR 1.78, 95% CI 1.27 to 2.48). A study reporting a similar outcome in Atlanta, GA, USA, at the time of the 1996 Olympic Games compared paediatric hospital admissions for asthma during the games period with the four weeks before and four weeks after the games.18 The authors found decreases in care events by using a variety of markers of health service use: Medicaid claims (RR 0.61, 95% CI 0.44 to 0.85), health maintenance organisation (US healthcare provider) claims (RR 0.56, 95% CI 0.31 to 1.02), data from two paediatric hospitals (admissions decreased by 11.1%), and data in the state of Georgia hospital discharge database (discharges decreased by 19.1%). The reported decrease in paediatric asthma events in Atlanta was associated with a 22.5% decrease in peak traffic counts during the Olympic Games and a 27.9% decrease in peak ozone levels in the city (P<0.001 for both compared with 4 weeks before the start of the games). Another study of the 1996 Olympic Games reported that 263 children from outside the local catchment area were seen at Atlanta hospitals around the time of the games (13 July to 13 August).19 The mean age of these children was 6.7 years, and 24% were seen in tertiary care centres and 76% in urgent care centres. The children originated from 23 countries and had 15 primary languages. A greater proportion of these 263 children required hospital admission during the event compared with local children (27% v 13%, respectively, at the tertiary hospital and 7% v 3%, respectively, at the county hospital), and 44% of these children were uninsured. A repeat cross-sectional study of presentations to hospital with problems induced by illicit drugs during the Olympic Games in Sydney, Australia, in 2000 and the two weeks before the games reported an increase in the mean daily number of presentations of 4.5 (from 8.8 to 13.3; P=0.04).20 Presentations peaked 24 hours after the closing ceremony (35.0 per day) and were higher at weekends (16.6 v with 9.2 during the week; P=0.001). Presentations of ecstasy related and amphetamine related problems increased during the games (daily mean of 5.1 compared with 1.7 during the two weeks before; P=0.007) but the level of heroin related presentations was unchanged (daily mean of 4.5 compared with 4.2; P=0.8). Australian residents comprised 90% of the presentations.

Recreation impacts One study reported that overall sports participation (four or more times in the past four weeks, except walking) decreased in the Manchester area of the UK by 2% after the 2002 Commonwealth Games, and that the gap in participation rates between individuals in affluent areas and those in deprived areas widened significantly (table 1⇑).21 On the other hand, there was an upward trend in sports participation from the early 1980s until 1994 in association with the 1992 Olympic Games in Barcelona, Spain.22 A second study examining the 2002 Commonwealth Games in Manchester suggested that it was difficult to reap sports legacy gains in this case because of problems with funding and capacity, the exclusion of voluntary groups from using event branding, and a failure to retain key staff after the games. It was also suggested that the provision of new sports facilities benefited elite athletes after the event more than the host population.23 However, satisfaction with green spaces in Manchester did increase after the event (from 28% to 75%).24

Economic impacts The outcomes most commonly assessed in studies on the impacts of major multi-sports events were economic growth and employment (table 2⇑). Although most studies associated major multi-sports events with increased economic growth and employment, these studies often used largely estimated data, had a very short post-event data collection period, and failed to take account of the opportunity costs of hosting large events, thus limiting the validity of the overall results.24 25 26 27 28 29 30 31 32 33 34 35 36 Some of the studies with longer data collection periods, less estimated data, and more collected data described some negative growth and detrimental impacts on employment.32 37 38 Inflation increased in Barcelona31 39 and Atlanta,31 but not in Sydney,31 40 in the run up to hosting the Olympic Games. Investment in sports infrastructure in Sydney was associated with a delay in health and education capital investment.41 Two studies reported that becoming a host city for the Olympic Games was associated with higher investment, as approximated by increased stock market indices.42 43 Two qualitative studies of business development activity at the Sydney Olympic Games in 2000 found that regions that focused on the development of a long term business network to generate better networking and market access fared better than areas that focused on short term benefits from attracting visitors.44 45 Business was perceived to have benefited from the 1988 Olympic Games in Calgary, AB, Canada,46 and from business assistance offered during the 2002 Commonwealth Games in Manchester.35

Impacts on transport and the environment Studies of five cities (Atlanta18 47; Busan17 48; Los Angeles, CA, USA49; Seattle, WA, USA 50; and Sydney51) examined the impact of transport mitigation strategies put in place during major sports events, such as restrictions on car use, increased public transport availability, promotion of car sharing, and increased working hours flexibility. A fall in air pollution was reported in two cities: Atlanta18 and Busan (level 2+).17 A lower quality study in Busan reported an increase in pollution.48 Road traffic volume decreased in Atlanta and Busan ,18 47 48 50 as did car journey time in Los Angeles and Sydney.49 51 A small study (n=12 households) reported increased aircraft noise and night time wakings around the time of the Olympic Games among residents living close to the airports in Atlanta.52

Impacts on volunteers Three studies examined the impacts of major multi-sports events on event volunteers. They reported that volunteers at the 2002 Manchester Commonwealth Games had a mix of positive and negative experiences53; no change in their desire to volunteer in the future53 54; and no increase in sports participation.53 54 However, one study did find that volunteers at the 1994 Winter Olympic Games in Lillehammer, Norway, and the 2000 Olympic Games in Sydney perceived an increase in their skills after volunteering.55