Getting strategic about the environment and health

The Contribution of Environmental Science to Mental Health Research: A Scoping Review

Mental health is influenced by multiple complex and interacting genetic, psychological, social, and environmental factors. As such, developing state-of-the-art mental health knowledge requires collaboration across academic disciplines, including environmental science. To assess the current contribution of environmental science to this field, a scoping review of the literature on environmental influences on mental health (including conditions of cognitive development and decline) was conducted. The review protocol was developed in consultation with experts working across mental health and environmental science. The scoping review included 202 English-language papers, published between 2010 and 2020 (prior to the COVID-19 pandemic), on environmental themes that had not already been the subject of recent systematic reviews; 26 reviews on climate change, flooding, air pollution, and urban green space were additionally considered. Studies largely focused on populations in the USA, China, or Europe and involved limited environmental science input. Environmental science research methods are primarily focused on quantitative approaches utilising secondary datasets or field data. Mental health measurement was dominated by the use of self-report psychometric scales. Measures of environmental states or exposures were often lacking in specificity (e.g., limited to the presence or absence of an environmental state). Based on the scoping review findings and our synthesis of the recent reviews, a research agenda for environmental science's future contribution to mental health scholarship is set out. This includes recommendations to expand the geographical scope and broaden the representation of different environmental science areas, improve measurement of environmental exposure, prioritise experimental and longitudinal research designs, and giving greater consideration to variation between and within communities and the mediating pathways by which environment influences mental health. There is also considerable opportunity to increase interdisciplinarity within the field via the integration of conceptual models, the inclusion of mixed methods and qualitative approaches, as well as further consideration of the socio-political context and the environmental states that can help support good mental health. The findings were used to propose a conceptual model to parse contributions and connections between environmental science and mental health to inform future studies.

Classification of Regional Healthy Environment and Public Health in China

Environmental pollution has become a hot topic of concern for the government, academia and the public. The evaluation of environmental health should not only relate to environmental quality and exposure channels but also the level of economic development, social environmental protection responsibility and public awareness. We put forward the concept of the "healthy environment" and introduced 27 environmental indicators to evaluate and classify the healthy environment of 31 provinces and cities in China. Seven common factors were extracted and divided into economic, medical, ecological and humanistic environment factors. Based on the four environmental factors, we classify the healthy environment into five categories-economic leading healthy environment, robust healthy environment, developmental healthy environment, economic and medical disadvantageous healthy environment and completely disadvantageous healthy environment. The population health differences among the five healthy environment categories show that economic environment plays a major role in population health. Public health in regions with sound economic environment is significantly better than that in other areas. Our classification result of healthy environment can provide scientific support for optimizing environmental countermeasures and realizing environmental protection.

Determining the effect of air quality on activities of daily living disability: using tracking survey data from 122 cities in China

Background

Current research on activities of daily living (ADLs) disability has mostly focused on the analysis of demographic characteristics, while research on the microcharacteristics of individuals and the macroenvironment is relatively limited, and these studies solely concern the impact of air quality on individual health.

Methods

This study innovatively investigated the impact of air quality on ADL disability by matching micro data of individuals from the China Health and Retirement Longitudinal Study with data of urban environmental quality from 122 cities. In this study, an ordered panel logit model was adopted for the benchmark test, and the two-stage ordered probit model with IV was used for endogenous treatment.

Results

This innovative study investigated the impact of air quality on ADL disability by matching individual micro data from the China Health and Retirement Longitudinal Study with urban environmental quality data for 122 cities. The results showed that air quality significantly increased the probability of ADL disability. The positive and marginal effect of air quality on moderate and mild disability was higher. Generally, the marginal effect of air quality on residents’ health was negative. In terms of group heterogeneity, the ADL disability of individuals aged over 60 years, those in the high Gross Domestic Product (GDP) group, females, and those in the nonpilot long-term care insurance group was more affected by air quality, and the interaction between air quality and serious illness showed that the deterioration of air quality exacerbated the ADL disability caused by serious illness; that is, the moderating effect was significant.

Conclusions

According to the equilibrium condition of the individual health production function, the ADL disability caused by a 1% improvement in air quality is equivalent to the ADL disability caused by an 89.9652% reduction in serious illness, indicating that the effect of improved air quality is difficult to replace by any other method. Therefore, good air quality can not only reduce ADL disability directly but also reduce serious illness indirectly, which is equivalent to the reduction of ADL disability. This is called the health impact.

Existing evidence on antibiotic resistance exposure and transmission to humans from the environment: a systematic map

BACKGROUND

Antimicrobial resistance (AMR) is predicted to become the leading cause of death by 2050 with antibiotic resistance being an important component. Anthropogenic pollution introduces antibiotic resistant bacteria (ARB) and antibiotic resistance genes (ARGs) to the natural environment. Currently, there is limited empirical evidence demonstrating whether humans are exposed to environmental AMR and whether this exposure can result in measurable human health outcomes. In recent years there has been increasing interest in the role of the environment and disparate evidence on transmission of AMR to humans has been generated but there has been no systematic attempt to summarise this. We aim to create two systematic maps that will collate the evidence for (1) the transmission of antibiotic resistance from the natural environment to humans on a global scale and (2) the state of antibiotic resistance in the environment in the United Kingdom.

METHODS

Search strategies were developed for each map. Searches were undertaken in 13 bibliographic databases. Key websites were searched and experts consulted for grey literature. Search results were managed using EndNote X8. Titles and abstracts were screened, followed by the full texts. Articles were double screened at a minimum of 10% at both stages with consistency checking and discussion when disagreements arose. Data extraction occurred in Excel with bespoke forms designed. Data extracted from each selected study included: bibliographic information; study site location; exposure source; exposure route; human health outcome (Map 1); prevalence/percentage/abundance of ARB/antibiotic resistance elements (Map 2) and study design. EviAtlas was used to visualise outputs.

RESULTS

For Map 1, 40 articles were included, from 11,016 unique articles identified in searches, which investigated transmission of AMR from the environment to humans. Results from Map 1 showed that consumption/ingestion was the most studied transmission route. Exposure (n = 17), infection (n = 16) and colonisation (n = 11) being studied as an outcome a similar number of times, with mortality studied infrequently (n = 2). In addition, E. coli was the most highly studied bacterium (n = 16). For Map 2, we included 62 studies quantifying ARB or resistance elements in the environment in the UK, from 6874 unique articles were identified in the searches. The most highly researched species was mixed communities (n = 32). The most common methodology employed in this research question was phenotypic testing (n = 37). The most commonly reported outcome was the characterisation of ARBs (n = 40), followed by characterisation of ARGs (n = 35). Other genetic elements, such as screening for intI1 (n = 15) (which encodes a Class 1 integron which is used as a proxy for environmental ARGs) and point mutations (n = 1) were less frequently reported. Both maps showed that research was focused towards aquatic environments.

CONCLUSIONS

Both maps can be used by policy makers to show the global (Map 1) and UK (Map 2) research landscapes and provide an overview of the state of AMR in the environment and human health impacts of interacting with the environment. We have also identified (1) clusters of research which may be used to perform meta-analyses and (2) gaps in the evidence base where future primary research should focus.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1186/s13750-022-00262-2.

A Food Security Indicator Framework for British Columbia, Canada

Food security is a determinant of health and increasingly recognized as a focus for health promotion. Led by the Population and Public Health Program, British Columbia Centre for Disease Control, this article outlines the process of development and the evidence-based conceptual framework that guides the systematic selection of food security indicators in the Province. A phased, iterative approach to develop the food security framework was adopted. Phase 1 consisted of a literature search of food security indicator models, and key informant discussions. Phase 2 consisted of modification of the model based on stakeholder consultation. The framework development occurred between January 2016 and April 2019. A structured scan of the literature found no existing conceptual frameworks specific to food security indicators in the Global North. The most relevant and frequently used frameworks for indicator reporting identified were environmental health indicator frameworks. This article presents a matrix framework based on existing environmental health indicator frameworks. It integrates environmental health causal networks (e.g., determinants-current state-impact-response) with food security elements identified as (a) individual and household food insecurity, (b) food systems, and (c) capacity. This framework contributes to food security performance monitoring in the Global North and fills an important gap in evaluating the impact of the public health response to food security. Use of this comprehensive framework can enable program planners and policy makers to be clear about where and how they are attempting to assess, influence and monitor food security, and illustrate the interconnectedness between indicators.

The Coexistence Potential of Different Wildlife Conservation Frameworks in a Historical Perspective

Wildlife management in contemporary society means balancing multiple demands in shared landscapes. Perhaps the greatest question facing today's policy makers and wildlife professionals is how to develop frameworks for coexistence between wildlife and the plethora of other land use interests. As a profession, the roots of wildlife management and conservation can be traced back to the 1600's, but most of the relevant frameworks that have shaped the management of wildlife over time have emerged after the mid-1800's and particularly since the 1960's. Here we examine the historical development of the main traits and concepts of a number of management and conservation frameworks that have all contributed to the multifaceted field of contemporary wildlife management and conservation in Europe and North America. We outline a chronology of concepts and ideologies with their underlying key ideas, values, and operational indicators, and make an assessment of the potential of each paradigm as a coexistence framework for dealing with wildlife. We tie this to a discussion of ethics and argue that the lack of unity in approaches is deeply embedded in the differences between rule-based (deontological) vs. results-based (consequentialist) or context dependent (particularist) ethics. We suggest that some of the conflicts between ideologies, value sets and frameworks can be resolved as an issue of scale and possibly zonation in shared landscapes. We also argue that approaches built on anthropocentrism, value pluralism and environmental pragmatism are most likely to succeed in complex socio-political landscapes. However, we caution against moral relativism and the belief that all types of cultural values are equally valid as a basis for contemporary wildlife management.

Conceptual frameworks regarding waterborne diseases in sub-Saharan Africa and the need of for a new approach to urban exposomes

Sub-Saharan African countries, like many other low-income countries, have experienced urban socioeconomic inequalities due to rapid and unplanned urbanization. These processes have resulted in the creation of poor urban areas lacking basic sanitation, water, and hygiene facilities, and subjacent public health issues such as the spread of waterborne diseases. A system for the demarcation of disease transmission areas already exists, but the traditional framework is less appropriate in sub-Saharan Africa, making it necessary to divide these urban areas more adequately. In addition, the construction of frameworks and tools more specific to waterborne disease-related issues is essential. We propose restructuring sub-Saharan urban areas into more specific areas of exposure to waterborne diseases and associated exposomes, and then use this restructuring of urban areas of exposure to waterborne diseases in a conceptual framework that takes into account causes of exposure, impacts, and interventions. The division of urban areas into public, domestic, and individual exposure areas facilitates a more straightforward understanding of the dynamics of waterborne exposomes. Moreover, the inclusion of this division in the driving force-pressure-state-exposure-effect-action framework allows an effective stratified implementation of urban public health policies.

Lessons from an International Initiative to Set and Share Good Practice on Human Health in Environmental Impact Assessment

Environmental Impact Assessment (EIA) is applied to infrastructure and other large projects. The European Union EIA Directive (2011/92/EU as amended by 2014/52/EU) requires EIAs to consider the effects that a project might have on human health. The International Association for Impact Assessment and the European Public Health Association prepared a reference paper on public health in EIA to enable the health sector to contribute to this international requirement. We present lessons from this joint action. We review literature on policy analysis, impact assessment and Health Impact Assessment (HIA). We use findings from this review and from the consultation on the reference paper to consider how population and human health should be defined; how the health sector can participate in the EIA process; the relationship between EIA and HIA; what counts as evidence; when an effect should be considered ‘likely’ and ‘significant’; how changes in health should be reported; the risks from a business-as-usual coverage of human health in EIA; and finally competencies for conducting an assessment of human health. This article is relevant for health authorities seeking to ensure that infrastructure, and other aspects of development, are not deleterious to, but indeed improve, human health.

What is the research evidence for antibiotic resistance exposure and transmission to humans from the environment? A systematic map protocol

BACKGROUND

Antimicrobial resistance (AMR) is a public health crisis that is predicted to cause 10 million deaths per year by 2050. The environment has been implicated as a reservoir of AMR and is suggested to play a role in the dissemination of antibiotic resistance genes (ARGs). Currently, most research has focused on measuring concentrations of antibiotics and characterising the abundance and diversity of ARGs and antibiotic resistant bacteria (ARB) in the environment. To date, there has been limited empirical research on whether humans are exposed to this, and whether exposure can lead to measureable impacts on human health. Therefore, the objective of this work is to produce two linked systematic maps to investigate previous research on exposure and transmission of AMR to humans from the environment. The first map will investigate the available research relating to exposure and transmission of ARB/ARGs from the environment to humans on a global scale and the second will investigate the prevalence of ARB/ARGs in various environments in the UK. These two maps will be useful for policy makers and research funders to identify where there are significant gluts and gaps in the current research, and where more primary and synthesis research needs to be undertaken.

METHODS

Separate search strategies will be developed for the two maps. Searches will be run in 13 databases, and grey literature will be sought from key websites and engagement with experts. Hits will be managed in EndNote and screened in two stages (title/abstract then full text) against predefined inclusion criteria. A minimum of 10% will be double screened with ongoing consistency checking. All included studies will have data extracted into a bespoke form designed and piloted for each map. Data to be extracted will include bibliographic details, study design, location, exposure source, exposure route, health outcome (Map 1); and prevalence/percentage of ARB/ARG (Map 2). No validity appraisal will be undertaken. Results will be tabulated and presented narratively, together with graphics showing the types and areas of research that has been undertaken and heatmaps for key exposure-health outcomes (Map 1) and exposure-prevalence (Map 2).

Rethinking conceptual frameworks and models of health and natural environments

This article considers conceptual frameworks and models applied in research about the multiple relations between human contact with natural environments (specifically green public spaces), diverse kinds of human activities and uses of those spaces, and effects on physical and mental health. Conceptual frameworks are tools for thinking about such complex subjects. Conceptual models represent the multiple relations between key factors and variables. These models can be used to represent the mutual interactions between the core components of environmental conditions of specific green public spaces, the main kinds of human activities in those settings, and various impacts on health. A literature search showed that the authors of various conceptual models used a metaphor of pathways to represent relations between explanatory variables by linear cause–effect relations. Mutual interaction between key variables and feedback loops between different components of the model are rarely included. Hence, it is argued that these models do not represent the complexity of real world situations. The authors propose a systemic conceptual framework founded on core principles of human ecology. The proposed conceptual framework and model have been formulated during and after an EU 7th Framework project about the ‘‘Positive Health Effects of the Natural Outdoor Environment in Typical Populations in Different Regions of Europe.”

Health impacts of environmental and social interventions designed to increase deprived communities’ access to urban woodlands: a mixed-methods study

Background

Contact with natural environments can bring health benefits, but research is lacking on how changes in access to natural environments might improve health, especially for deprived populations.

Objective

To evaluate the health impacts of woodland environment interventions intended to increase communities’ engagement with these woodlands.

Design

A prospective study of Forestry Commission Scotland’s Woods In and Around Towns (WIAT) programme in deprived communities to enhance public access to natural environments. The study investigated the impact that WIAT had on community-level mental health over time.

Setting

Three intervention and three control woodland sites, and associated communities within 1.5 km of the woodlands, located in central Scotland and eligible for WIAT support.

Participants

A core community survey was administered at each site in three waves, at baseline and after each phase of intervention (n = 5460, panel A). The completed survey contained a nested longitudinal cohort (n = 609, panel B). Community members also undertook 6-monthly environmental audits at all sites (n = 256) and participated in post-intervention focus groups (n = 34).

Interventions

Phase 1 involved physical changes to the woodlands, including footpaths, entrances and vegetation. Phase 2 involved community engagement events promoting woodland use.

Main outcome measures

The primary outcome was the Perceived Stress Scale (PSS). Other health measures included health-related quality of life (HRQoL) EuroQol-5 Dimensions (EQ-5D), physical activity (PA) [International Physical Activity Questionnaire (IPAQ)], connectedness to nature [Inclusion of Nature in Self (INS) scale] and social cohesion.

Results

The PSS scores significantly increased in the intervention group and marginally decreased in the control group. Multilevel regression models showed a differential impact between the intervention and the control at survey wave 3 in panel A [B(unstandardised coefficient) 3.58, 95% confidence interval (CI) 2.85 to 4.31;p < 0.001] and in panel B [B3.03, 95% CI 1.54 to 4.52;p < 0.001]. Using the same analytical approach, no significant change in HRQoL was associated with the intervention. Economic assessment included an illustrative cost–utility analysis and a cost–consequences analysis. The differential in stress between the intervention group and the control group was lower or non-significant in those who visited ‘nature’ in the previous year [panel A,B1.9, 95% CI 0.8 to 3.0;p < 0.001; panel B,B0.64, 95% CI –1.60 to 2.88;p = 0.57]. The IPAQ score showed a positive association with the intervention for moderate levels of PA [panel B,B559.3, 95% CI 211.3 to 907.2;p = 0.002] and overall PA [panel B,B861.5, 95% CI 106.5 to 1616.4;p = 0.025]. The intervention was also associated with increased nature connectedness and social cohesion by wave 3 – significant for panel A only. Qualitative and quantitative evidence showed that interventions increased the perceived quality of the woodland environment and enhanced its enjoyment for different activities, but the increase in use of natural environments post intervention was only 6% (panel B).

Limitations

This study was limited to three intervention sites. External factors may be the primary influence on health outcomes.

Conclusions

The WIAT interventions did not improve community-level health within 6 months of completion, and hence there was no basis for demonstrating cost-effectiveness. However, the WIAT interventions are low cost (average £11.80 per person in the eligible population) and have potential for cost-effectiveness, if health benefits were found in the longer term.

Future work

Using routinely collected data to consider a whole-programme evaluation is recommended.

Funding

The National Institute for Health Research Public Health Research programme.

The nexus between climate change, ecosystem services and human health: Towards a conceptual framework

This paper addresses the impact that changes in natural ecosystems can have on health and wellbeing focusing on the potential co-benefits that green spaces could provide when introduced as climate change adaptation measures. Ignoring such benefits could lead to sub-optimal planning and decision-making. A conceptual framework, building on the ecosystem-enriched Driver, Pressure, State, Exposure, Effect, Action model (eDPSEEA), is presented to aid in clarifying the relational structure between green spaces and human health, taking climate change as the key driver. The study has the double intention of (i) summarising the literature with a special emphasis on the ecosystem and health perspectives, as well as the main theories behind these impacts, and (ii) modelling these findings into a framework that allows for multidisciplinary approaches to the underlying relations between human health and green spaces. The paper shows that while the literature based on the ecosystem perspective presents a well-documented association between climate, health and green spaces, the literature using a health-based perspective presents mixed evidence in some cases. The role of contextual factors and the exposure mechanism are rarely addressed. The proposed framework could serve as a multidisciplinary knowledge platform for multi-perspecitve analysis and discussion among experts and stakeholders, as well as to support the operationalization of quantitative assessment and modelling exercises.

The INHERIT Model: A Tool to Jointly Improve Health, Environmental Sustainability and Health Equity through Behavior and Lifestyle Change

The need for analysis and action across the interrelated domains of human behaviors and lifestyles, environmental sustainability, health and inequality is increasingly apparent. Currently, these areas are often not considered in conjunction when developing policies or interventions, introducing the potential for suboptimal or conflicting outcomes. The INHERIT model has been developed within the EU-funded project INHERIT as a tool to guide thinking and intersectoral action towards changing the behaviors and lifestyles that play such an important role in today’s multidisciplinary challenges. The model integrates ecological public health and behavioral change models, emphasizing inequalities and those parts of the causal process that are influenced by human behaviors and lifestyles. The model was developed through web-based and live discussions with experts and policy stakeholders. To test the model’s usability, the model was applied to aspects of food consumption. This paper shows that the INHERIT model can serve as a tool to identify opportunities for change in important −food-related behaviors and lifestyles and to examine how they impact on health, health inequalities, and the environment in Europe and beyond. The INHERIT model helps clarify these interrelated domains, creating new opportunities to improve environmental health and health inequality, while taking our planetary boundaries into consideration.

Scoping the proximal and distal dimensions of climate change on health and wellbeing

The impacts of climate on health and wellbeing occur in time and space and through a range of indirect, complicated mechanisms. This diversity of pathways has major implications for national public health planning and influence on interventions that might help to mitigate and adapt to rapidly changing environmental conditions, nationally and internationally. This paper draws upon evidence from public health and adverse impact studies across climate science, hydrology, agriculture, public health, and the social sciences. It presents a conceptual model to support decision-making by recognizing both the proximal and distal pathways from climate-induced environmental change to national health and wellbeing. The proximal and distal pathways associated with food security, migration and mobility illustrate the diverse climate change influences in different geographic locations over different timescales. We argue that greater realization and articulation of proximal and distal pathways should radically alter how climate change is addressed as a national and international public health challenge.

Integrated monitoring for environmental health impact assessment related to the genotoxic effects of vehicular pollution in Uberlândia, Brazil

The development of parameters to explore the link between air-related diseases and their significant driving forces is an important aim in terms of national economics and public health. In this study, we did an integrated analysis involving multiple environmental health indicators from Uberlândia, Brazil, registered before and during a period when the Brazilian government reduced taxes on new cars in a bid to bolster local manufacturing. In addition, the present study utilized Driving Force-Pressure-State-Exposure-Effect-Action (DPSEEA) frameworks to evaluate correlations in environmental health indicators over 10 years (2004-2013), in which the Brazilian government reduced vehicle production taxes beginning in 2008. Significant correlations in all indicators selected were found from 2008 to 2013, corresponding to the tax reduction on new vehicles. The frequency of micronuclei (MN) was significantly higher in the city center compared to the reference site, with the highest MN levels observed during the period of reduced taxes. Results reinforced the need to adopt air quality monitoring programs in major cities.

Social determinants and lifestyles: integrating environmental and public health perspectives

OBJECTIVE

Industrialization and urbanization have been associated with an epidemiological transition, from communicable to non-communicable disease, and a geological transition that is moving the planet beyond the stable Holocene epoch in which human societies have prospered. The lifestyles of high-income countries are major drivers of these twin processes. Our objective is to highlight the common causes of chronic disease and environmental change and, thereby, contribute to shared perspectives across public health and the environment.

STUDY DESIGN

Integrative reviews focused on social determinants and lifestyles as two 'bridging' concepts between the fields of public health and environmental sustainability.

METHODS

We drew on established frameworks to consider the position of the natural environment within social determinants of health (SDH) frameworks and the position of social determinants within environmental frameworks. We drew on evidence on lifestyle factors central to both public health and environmental change (mobility- and diet-related factors). We investigated how public health's focus on individual behaviour can be enriched by environmental perspectives that give attention to household consumption practices.

RESULTS

While SDH frameworks can incorporate the biophysical environment, their causal structure positions it as a determinant and one largely separate from the social factors that shape it. Environmental frameworks are more likely to represent the environment and its ecosystems as socially determined. A few frameworks also include human health as an outcome, providing the basis for a combined public health/environmental sustainability framework. Environmental analyses of household impacts broaden public health's concern with individual risk behaviours, pointing to the more damaging lifestyles of high-income households.

CONCLUSION

The conditions for health are being undermined by rapid environmental change. There is scope for frameworks reaching across public health and environmental sustainability and a shared evidence base that captures the health- and environmentally damaging impacts of high-consumption lifestyles.

Mapping Environmental Inequalities Relevant for Health for Informing Urban Planning Interventions-A Case Study in the City of Dortmund, Germany

Spatial differences in urban environmental conditions contribute to health inequalities within cities. The purpose of the paper is to map environmental inequalities relevant for health in the City of Dortmund, Germany, in order to identify needs for planning interventions. We develop suitable indicators for mapping socioeconomically-driven environmental inequalities at the neighborhood level based on published scientific evidence and inputs from local stakeholders. Relationships between socioeconomic and environmental indicators at the level of 170 neighborhoods were analyzed continuously with Spearman rank correlation coefficients and categorically applying chi-squared tests. Reclassified socioeconomic and environmental indicators were then mapped at the neighborhood level in order to determine multiple environmental burdens and hotspots of environmental inequalities related to health. Results show that the majority of environmental indicators correlate significantly, leading to multiple environmental burdens in specific neighborhoods. Some of these neighborhoods also have significantly larger proportions of inhabitants of a lower socioeconomic position indicating hotspots of environmental inequalities. Suitable planning interventions mainly comprise transport planning and green space management. In the conclusions, we discuss how the analysis can be used to improve state of the art planning instruments, such as clean air action planning or noise reduction planning towards the consideration of the vulnerability of the population.

Newborns health in the Danube Region: Environment, biomonitoring, interventions and economic benefits in a large prospective birth cohort study

BACKGROUND

The EU strategy for the Danube Region addresses numerous challenges including environment, health and socioeconomic disparities. Many old environmental burdens and heavily polluted areas in Europe are located in the Danube Region, consisting of 14 countries, with over 100 million people. Estimating the burden of environmental exposures on early-life health is a growing research area in Europe which has major public health implications, but the data from the Danube Region are largely missing.

AIM

This review presents an inventory of current environmental challenges, related early-life health risks, and knowledge gaps in the Danube Region, based on publicly available databases, registers, and literature, as a rationale and incentive for a new integrated project. The review also proposes the concept for the project aiming to characterize in utero exposures to multiple environmental factors and estimate their effect on early-life health, evaluate economic impact, as well as identify interventions with a potential to harness social norms to reduce emissions, exposures and health risks in the Danube Region.

METHODS

Experts in environmental epidemiology, human biomonitoring and social science in collaboration with clinicians propose to establish a new large multi-center birth cohort of mother-child pairs from Danube countries, measure biomarkers of exposure and health in biological samples at birth, collect centrally measured climate, air and water pollution data, conduct pre- and postnatal surveys on lifestyle, indoor exposures, noise, occupation, socio-economic status, risk-averting behavior, and preferences; and undertake clinical examinations of children at and after birth. Birth cohort will include at least 2000 newborns per site, and a subset of at least 200 mother-child pairs per site for biomonitoring. Novel biomarkers of exposure, susceptibility, and effect will be applied, to gain better mechanistic insight. Effects of multiple environmental exposures on fetal and child growth, respiratory, allergic, immunologic, and neurodevelopmental health outcomes will be estimated. Parent's willingness to pay for reducing health risks in children will be elicited by survey, while values of cost-of-illness will be gathered from literature and national statistics. Effects of risk reducing interventions will be examined.

CONCLUSIONS

The proposed project would provide novel estimates of the burden of early childhood diseases attributable to environmental exposures and assess health impacts of different intervention scenarios in the Danube Region, in an integrated approach combining human biomonitoring, epidemiological and social science research.

Growing pains: How risk perception and risk communication research can help to manage the challenges of global population growth

In 2011, the global human population reached 7 billion and medium variant projections indicate that it will exceed 9 billion before 2045. Theoretical and empirical perspectives suggest that this growth could lead to an increase in the likelihood of adverse events (e.g., food shortages, climate change, etc.) and/or the severity of adverse events (e.g., famines, natural disasters, etc.). Several scholars have posited that the size to which the global population grows and the extent to which this growth increases the likelihood of adverse outcomes will largely be shaped by individuals' decisions (in households, organizations, governments, etc.). In light of the strong relationship between perceived risk and decision behaviors, it is surprising that there remains a dearth of empirical research that specifically examines the perceived risks of population growth and how these perceptions might influence related decisions. In an attempt to motivate this important strand of research, this article examines the major risks that may be exacerbated by global population growth and draws upon empirical work concerning the perception and communication of risk to identify potential directions for future research. The article also considers how individuals might perceive both the risks and benefits of population growth and be helped to better understand and address the related issues. The answers to these questions could help humanity better manage the emerging consequences of its continuing success in increasing infant survival and adult longevity.

Human health and the water environment: using the DPSEEA framework to identify the driving forces of disease

There is a growing awareness of global forces that threaten human health via the water environment. A better understanding of the dynamic between human health and the water environment would enable prediction of the significant driving forces and effective strategies for coping with or preventing them. This report details the use of the Driving Force-Pressure-State-Exposure-Effect-Action (DPSEEA) framework to explore the linkage between water-related diseases and their significant driving forces. The DPSEEA frameworks indicate that a select group of driving forces, including population growth, agriculture, infrastructure (dams and irrigation), and climate change, is at the root cause of key global disease burdens. Construction of the DPSEEA frameworks also allows for the evaluation of public health interventions. Sanitation was found to be a widely applicable and effective intervention, targeting the driver/pressure linkage of most of the water-related diseases examined. Ultimately, the DPSEEA frameworks offer a platform for constituents in both the health and environmental fields to collaborate and commit to a common goal targeting the same driving forces.

The portrayal of natural environment in the evolution of the ecological public health paradigm

This paper explores the conceptualization of the natural environment in an evolving ecological public health paradigm. The natural environment has long been recognized as essential to supporting life, health, and wellbeing. Our understanding of the relationship between the natural environment and health has steadily evolved from one of an undynamic environment to a more sophisticated understanding of ecological interactions.  This evolution is reflected in a number of ecological public health models which demonstrate the many external and overlapping determinants of human health. Six models are presented here to demonstrate this evolution, each model reflecting an increasingly ecological appreciation for the fundamental role of the natural environment in supporting human health. We conclude that after decades of public health's acceptance of the ecological paradigm, we are only now beginning to assemble knowledge of sophisticated ecological interdependencies and apply this knowledge to the conceptualization and study of the relationship between the natural environment and the determinants of human health.

Integrating health and environmental impact analysis

Scientific investigations have progressively refined our understanding of the influence of the environment on human health, and the many adverse impacts that human activities exert on the environment, from the local to the planetary level. Nonetheless, throughout the modern public health era, health has been pursued as though our lives and lifestyles are disconnected from ecosystems and their component organisms. The inadequacy of the societal and public health response to obesity, health inequities, and especially global environmental and climate change now calls for an ecological approach which addresses human activity in all its social, economic and cultural complexity. The new approach must be integral to, and interactive, with the natural environment. We see the continuing failure to truly integrate human health and environmental impact analysis as deeply damaging, and we propose a new conceptual model, the ecosystems-enriched Drivers, Pressures, State, Exposure, Effects, Actions or 'eDPSEEA' model, to address this shortcoming. The model recognizes convergence between the concept of ecosystems services which provides a human health and well-being slant to the value of ecosystems while equally emphasizing the health of the environment, and the growing calls for 'ecological public health' as a response to global environmental concerns now suffusing the discourse in public health. More revolution than evolution, ecological public health will demand new perspectives regarding the interconnections among society, the economy, the environment and our health and well-being. Success must be built on collaborations between the disparate scientific communities of the environmental sciences and public health as well as interactions with social scientists, economists and the legal profession. It will require outreach to political and other stakeholders including a currently largely disengaged general public. The need for an effective and robust science-policy interface has never been more pressing. Conceptual models can facilitate this by providing theoretical frameworks and supporting stakeholder engagement process simplifications for inherently complex situations involving environment and human health and well-being. They can be tools to think with, to engage, to communicate and to help navigate in a sea of complexity. We believe models such as eDPSEEA can help frame many of the issues which have become the challenges of the new public health era and can provide the essential platforms necessary for progress.

How effective is the Forestry Commission Scotland's woodland improvement programme--'Woods In and Around Towns' (WIAT)--at improving psychological well-being in deprived urban communities? A quasi-experimental study

INTRODUCTION

There is a growing body of evidence that suggests that green spaces may positively influence psychological well-being. This project is designed to take advantage of a natural experiment where planned physical and social interventions to enhance access to natural environments in deprived communities provide an opportunity to prospectively assess impacts on perceived stress and mental well-being.

STUDY DESIGN AND METHODS

A controlled, prospective study comprising a repeat cross-sectional survey of residents living within 1.5 km of intervention and comparison sites. Three waves of data will be collected: prephysical environment intervention (2013); postphysical environment intervention (2014) and postwoodland promotion social intervention (2015). The primary outcome will be a measure of perceived stress (Perceived Stress Scale) preintervention and postintervention. Secondary, self-report outcomes include: mental well-being (Short Warwick-Edinburgh Mental Well-being Scale), changes in physical activity (IPAQ-short form), health (EuroQoL EQ-5D), perception and use of the woodlands, connectedness to nature (Inclusion of Nature in Self Scale), social cohesion and social capital. An environmental audit will complement the study by evaluating the physical changes in the environment over time and recording any other contextual changes over time. A process evaluation will assess the implementation of the programme. A health economics analysis will assess the cost consequences of each stage of the intervention in relation to the primary and secondary outcomes of the study.

ETHICS AND DISSEMINATION

Ethical approval has been given by the University of Edinburgh, Edinburgh College of Art Research, Ethics and Knowledge Exchange Committee (ref. 19/06/2012). Findings will be disseminated through peer-reviewed publications, national and international conferences and, at the final stage of the project, through a workshop for those interested in implementing environmental interventions.

Environmental health problems and indicators in tabriz, iran

BACKGROUND

Environmental Health Indicators (EHIs) are the most important criteria for evaluation of efficiency and effectiveness of the activities of the health sector. The operations and situation of the health system can be analyzed through surveying the indicators and comparing them during different times. The present study aimed to study the EHIs of Tabriz, using the common environmental health processes and national EHIs of the Ministry of Health.

METHOD

The required information for determination of EHIs was collected from different sources, including mainly the Environmental Health Department of the Health Center of East Azerbaijan Province, Iran and other organizations.

RESULTS

We found some important desirable and undesirable EHIs in Tabriz,including high percentage of households with access to safe and reliable drinking water, high safety in microbiological and chemical quality of drinking water, acceptable level of BOD5 and COD in the effluent of wastewater treatment plants (WTP), lack of complete municipal wastewater collection and treatment, relatively poor sanitation and health of food markets and public places, undesirable collection,transportation and disposal of municipal solid waste, low EHIs of some school classrooms, unacceptable disposal of medical waste in some hospitals, and finally high level of noise pollution in the city.

CONCLUSION

Considering the poor condition of some EHIs of Tabriz, implementing proper actions for promotion of the indicators especially development of municipal wastewater collection, improvement of solid waste management,environmental health of some schools and mosques, and finally the noise pollution level of the city is recommended.

Quantifying human exposure to air pollution--moving from static monitoring to spatio-temporally resolved personal exposure assessment

Quantifying human exposure to air pollutants is a challenging task. Ambient concentrations of air pollutants at potentially harmful levels are ubiquitous in urban areas and subject to high spatial and temporal variability. At the same time, every individual has unique activity-patterns. Exposure results from multifaceted relationships and interactions between environmental and human systems, adding complexity to the assessment process. Traditionally, approaches to quantify human exposure have relied on pollutant concentrations from fixed air quality network sites and static population distributions. New developments in sensor technology now enable us to monitor personal exposure to air pollutants directly while people are moving through their activity spaces and varying concentration fields. The literature review on which this paper is based on reflects recent developments in the assessment of human exposure to air pollution. This includes the discussion of methodologies and concepts, and the elaboration of approaches and study designs applied in the field. We identify shortcomings of current approaches and discuss future research needs. We close by proposing a novel conceptual model for the integrated assessment of human exposure to air pollutants taking into account latest technological capabilities and contextual information.

Approaches to integrated monitoring for environmental health impact assessment

Although Integrated Environmental Health Monitoring (IEHM) is considered an essential tool to better understand complex environmental health issues, there is no consensus on how to develop such a programme. We reviewed four existing frameworks and eight monitoring programmes in the area of environmental health. We identified the DPSEEA (Driving Force-Pressure-State-Exposure-Effect-Action) framework as most suitable for developing an IEHM programme for environmental health impact assessment. Our review showed that most of the existing monitoring programmes have been designed for specific purposes, resulting in narrow scope and limited number of parameters. This therefore limits their relevance for studying complex environmental health topics. Other challenges include limited spatial and temporal data availability, limited development of data sharing mechanisms, heterogeneous data quality, a lack of adequate methodologies to link disparate data sources, and low level of interdisciplinary cooperation. To overcome some of these challenges, we propose a DPSEEA-based conceptual framework for an IEHM programme that would enable monitoring and measuring the impact of environmental changes on human health. We define IEHM as 'a systemic process to measure, analyse and interpret the state and changes of natural-eco-anthropogenic systems and its related health impact over time at the same location with causative explanations across the various compartments of the cause-effect chain'. We develop a structural work process to integrate information that is based on existing environmental health monitoring programmes. Such a framework allows the development of combined monitoring systems that exhibit a large degree of compatibility between countries and regions.

How can a climate change perspective be integrated into public health surveillance?

OBJECTIVES

Climate change may be considered as a key factor for environmental change, exposure to health risks and pathogens, consequently impairing the state of health among populations. Efficient health surveillance systems are required to support adaptation to climate change. However, despite a growing awareness, the public health surveillance sector has had very little involvement in the drafting of adaptation plans. This paper proposes a method to raise awareness about climate change in the public health community, to identify possible health risks and to assess the needs for reinforced health surveillance systems.

METHODS

A working group was set up comprising surveillance experts in the following fields: environmental health; chronic diseases and; infectious diseases. Their goal was to define common objectives, to propose a framework for risk analysis, and to apply it to relevant health risks in France.

RESULTS

The framework created helped to organize available information on climate-sensitive health risks, making a distinction between three main determinants as follows: (1) environment; (2) individual and social behaviours; and (3) demography and health status. The process is illustrated using two examples: heatwaves and airborne allergens.

CONCLUSION

Health surveillance systems can be used to trigger early warning systems, to create databases which improve scientific knowledge about the health impacts of climate change, to identify and prioritize needs for intervention and adaptation measures, and to evaluate these measures. Adaptation requires public health professionals to consider climate change as a concrete input parameter in their studies and to create partnerships with professionals from other disciplines.

The obesity pandemic: implementing the evidence for children in Scottish families

BACKGROUND

Increasing obesity levels arise from multiple causes, which require understanding as a whole system. Co-ordinated action from heterogeneous groups with differing interests and perspectives is required to tackle rising obesity. To be effective, this must be targeted at identifying, agreeing and modifying the critical drivers.

OBJECTIVES

To illustrate an application of an environmental health systems modelling approach (as adapted in Scotland) to a particularly important Scottish topic: the rising obesity levels in Scottish children.

DISCUSSION

The model was able to capture an integration of the closely coupled causal chains around excessive energy intake and physical inactivity in children in their domestic environment. The model was able to incorporate action at different strategic levels.

CONCLUSIONS

Applying the Drivers, Pressures, State, Exposure, Effects, Actions (DPSEEA) model to the public health problem of child obesity allowed a clear view of a number of multiple causal chains involved in a particular environment. That clarity may be a necessary condition for co-ordinated action to create change.

A review of frameworks for developing environmental health indicators for climate change and health

The role climate change may play in altering human health, particularly in the emergence and spread of diseases, is an evolving area of research. It is important to understand this relationship because it will compound the already significant burden of diseases on national economies and public health. Authorities need to be able to assess, anticipate, and monitor human health vulnerability to climate change, in order to plan for, or implement action to avoid these eventualities. Environmental health indicators (EHIs) provide a tool to assess, monitor, and quantify human health vulnerability, to aid in the design and targeting of interventions, and measure the effectiveness of climate change adaptation and mitigation activities. Our aim was to identify the most suitable framework for developing EHIs to measure and monitor the impacts of climate change on human health and inform the development of interventions. Using published literature we reviewed the attributes of 11 frameworks. We identified the Driving force-Pressure-State-Exposure-Effect-Action (DPSEEA) framework as the most suitable one for developing EHIs for climate change and health. We propose the use of EHIs as a valuable tool to assess, quantify, and monitor human health vulnerability, design and target interventions, and measure the effectiveness of climate change adaptation and mitigation activities. In this paper, we lay the groundwork for the future development of EHIs as a multidisciplinary approach to link existing environmental and epidemiological data and networks. Analysis of such data will contribute to an enhanced understanding of the relationship between climate change and human health.

Are cars the new tobacco?

BACKGROUND

Public health must continually respond to new threats reflecting wider societal changes. Ecological public health recognizes the links between human health and global sustainability. We argue that these links are typified by the harms caused by dependence on private cars.

METHODS

We present routine data and literature on the health impacts of private car use; the activities of the 'car lobby' and factors underpinning car dependence. We compare these with experience of tobacco.

RESULTS

Private cars cause significant health harm. The impacts include physical inactivity, obesity, death and injury from crashes, cardio-respiratory disease from air pollution, noise, community severance and climate change. The car lobby resists measures that would restrict car use, using tactics similar to the tobacco industry. Decisions about location and design of neighbourhoods have created environments that reinforce and reflect car dependence. Car ownership and use has greatly increased in recent decades and there is little public support for measures that would reduce this.

CONCLUSIONS

Car dependence is a potent example of an issue that ecological public health should address. The public health community should advocate strongly for effective policies that reduce car use and increase active travel.

New approaches to problem framing in environmental health: application to water

The relationship between human health and water in its many forms illustrates rather well, the greatest contemporary challenge for decision makers in environmental health - how to develop coherent and effective policy in a climate of significant and increasing complexity. In the study of water and health we recognise the types of complexity that emerge for scientists and epidemiologists in assessing and communicating environmental health risk but also the difficulty for policy makers in interpreting such advice and integrating it with a wider environmental/public health intelligence to shape an effective and proportionate response. Taking water as a point of reference, this paper discusses the sources of complexity for decision makers in environmental health and describes an approach in Scotland which is seeking to build a more sophisticated approach to environmental health policy for a new and uniquely challenging public health era.

Impact of environmental discourses on public health policy arrangements: a comparative study in the UK and Flanders, (Belgium)

OBJECTIVES

Theoretically inspired by discursive institutionalism and multi-level governance, this paper assesses the extent to which 'environmental health' has emerged as a new discourse at European level, the effects it has had on national public health governance in two European countries, and what mechanisms have triggered or hindered these effects.

STUDY DESIGN

Comparison of the dynamics in public health policy arrangements in Flanders (Belgium) and the UK, nations influenced by both international and European environmental health discourses.

METHODS

The Policy Arrangement Approach was the analytical framework used to structure the results of this textual analysis.

RESULTS

Despite their shared focus on environmental health, Belgium and the UK display quite different approaches to environmental health governance. While Belgium works on environmental health in a predominantly top-down approach, the UK has developed a more inward-facing approach to environmental health policies.

CONCLUSION

The cases of the UK and Belgium show that, although these countries respond similarly to internationally agreed charters and both are members of the European Union, national differences in environmental health policies persist, mainly due to pre-existing national policy arrangements and the activities of national institutions. This leads to a divergent interplay between national and international institutions.

Injury prevention: a strategic priority for environmental health?

Injury results from the acute transfer of energy (or the acute lack of a vital element) from the environment to human tissue. It is thus, ipso facto, an 'environmental health' issue par excellence. This paper argues that injury consequently deserves consideration as a major strategic priority by environmental health professionals. Two international agreements concerning children's health and the environment have major implications for safety. The Children's Environmental Health Action Plan for Europe (CEHAPE) and the European Environmental Health Strategy make reference to the need for improved evidence and greater co-operation between the environmental and health sectors. CEHAPE is particularly relevant to safety as it focuses on four regional priority goals, the second of which refers to the prevention and reduction of health consequences from injuries by promoting safe, secure and supportive human settlements for all children. The natural strategic 'home' for injury prevention may therefore lie within environmental health, a domain from which it has generally been excluded. In support of this assertion, Scotland's recent policy initiative on the environment and human health 'Good Places, Better Health' is cited, where injury in children up to 8 years of age is one of four child health priorities being tackled during its initial implementation. An important test of the initiative may be its capacity to inform policy, practice and research in the field of injury prevention and safety promotion. If successful, it will help to validate the environmental health approach to a field that remains relatively neglected by public agencies, policy makers, practitioners and researchers.

Ecological public health and climate change policy

The fact that health and disease are products of a complex interaction of factors has long been recognized in public health circles. More recently, the term 'ecological public health' has been used to characterize an era underpinned by the paradigm that, when it comes to health and well-being, 'everything matters'. The challenge for policy makers is one of navigating this complexity to deliver better health and greater equality in health. Recent work in Scotland has been concerned to develop a strategic approach to environment and health. This seeks to embrace complexity within that agenda and recognize a more subtle relationship between health and place but remain practical and relevant to a more traditional hazard-focused environmental health approach. The Good Places, Better Health initiative is underpinned by a new problem-framing approach using a conceptual model developed for that purpose. This requires consideration of a wider social, behavioural etc, context. The approach is also used to configure the core systems of the strategy which gather relevant intelligence, subject it to a process of evaluation and direct its outputs to a broad policy constituency extending beyond health and environment. This paper highlights that an approach, conceived and developed to deliver better health and greater equality in health through action on physical environment, also speaks to a wider public health agenda. Specifically it offers a way to help bridge a gap between paradigm and policy in public health. The author considers that with development, a systems-based approach with close attention to problem-framing/situational modelling may prove useful in orchestrating what is a necessarily complex policy response to mitigate and adapt to climate change.

Associations between health and different types of environmental incivility: a Scotland-wide study

OBJECTIVES

Concern about the impact of the environment on health and well-being has tended to focus on the physical effects of exposure to toxic and infectious substances, and on the impact of large-scale infrastructures. Less attention has been paid to the possible psychosocial consequences of people's subjective perceptions of their everyday, street-level environment, such as the incidence of litter and graffiti. As little is known about the potential relative importance for health of perceptions of different types of environmental incivility, a module was developed for inclusion in the 2004 Scottish Social Attitudes survey in order to investigate this relationship.

STUDY DESIGN

A random sample of 1637 adults living across a range of neighbourhoods throughout Scotland was interviewed.

METHODS

Respondents were asked to rate their local area on a range of possible environmental incivilities. These incivilities were subsequently grouped into three domains: (i) street-level incivilities (e.g. litter, graffiti); (ii) large-scale infrastructural incivilities (e.g. telephone masts); and (iii) the absence of environmental goods (e.g. safe play areas for children). For each of the three domains, the authors examined the degree to which they were thought to pose a problem locally, and how far these perceptions varied between those living in deprived areas and those living in less-deprived areas. Subsequently, the relationships between these perceptions and self-assessed health and health behaviours were explored, after controlling for gender, age and social class.

RESULTS

Respondents with the highest levels of perceived street-level incivilities were almost twice as likely as those who perceived the lowest levels of street-level incivilities to report frequent feelings of anxiety and depression. Perceived absence of environmental goods was associated with increased anxiety (2.5 times more likely) and depression (90% more likely), and a 50% increased likelihood of being a smoker. Few associations with health were observed for perceptions of large-scale infrastructural incivilities.

CONCLUSIONS

Environmental policy needs to give more priority to reducing the incidence of street-level incivilities and the absence of environmental goods, both of which appear to be more important for health than perceptions of large-scale infrastructural incivilities.

Climate change and occupational safety and health: establishing a preliminary framework

The relationship between global climate change and occupational safety and health has not been extensively characterized. To begin such an effort, it may be useful to develop a framework for identifying how climate change could affect the workplace; workers; and occupational morbidity, mortality, and injury. This article develops such a framework based on a review of the published scientific literature from 1988-2008 that includes climatic effects, their interaction with occupational hazards, and their manifestation in the working population. Seven categories of climate-related hazards are identified: (1) increased ambient temperature, (2) air pollution, (3) ultraviolet exposure, (4) extreme weather, (5) vector-borne diseases and expanded habitats, (6) industrial transitions and emerging industries; and (7) changes in the built environment. This review indicates that while climate change may result in increasing the prevalence, distribution, and severity of known occupational hazards, there is no evidence of unique or previously unknown hazards. However, such a possibility should not be excluded, since there is potential for interactions of known hazards and new conditions leading to new hazards and risks.

Improving environmental sanitation, health, and well-being: a conceptual framework for integral interventions

We introduce a conceptual framework for improving health and environmental sanitation in urban and peri-urban areas using an approach combining health, ecological, and socioeconomic and cultural assessments. The framework takes into account the three main components: i) health status, ii) physical environment, and iii) socioeconomic and cultural environment. Information on each of these three components can be obtained by using standard disciplinary methods and an innovative combination of these methods. In this way, analyses lead to extended characterization of health, ecological, and social risks while allowing the comprehensive identification of critical control points (CCPs) in relation to biomedical, epidemiological, ecological, and socioeconomic and cultural factors. The proposed concept complements the conventional CCP approach by including an actor perspective that considers vulnerability to risk and patterns of resilience. Interventions deriving from the comprehensive analysis consider biomedical, engineering, and social science perspectives, or a combination of them. By this way, the proposed framework jointly addresses health and environmental sanitation improvements, and recovery and reuse of natural resources. Moreover, interventions encompass not only technical solutions but also behavioral, social, and institutional changes which are derived from the identified resilience patterns. The interventions are assessed with regards to their potential to eliminate or reduce specific risk factors and vulnerability, enhance health status, and assure equity. The framework is conceptualized and validated for the context of urban and peri-urban settings in developing countries focusing on waste, such as excreta, wastewater, and solid waste, their influence on food quality, and their related pathogens, nutrients, and chemical pollutants.