A perspective on green, blue, and grey spaces, biodiversity, microbiota, and human health

Humans have lived from equator to poles for millennia but are now increasingly intruding into the wild spaces of other species and steadily extruding ourselves from our own wild spaces, with a profound impact on: our relationship with the natural world; survival of other species; pollution; climate change; etc. We have yet to grasp how these changes directly impact our own health. The primary focus of this paper is on the beneficial influence of proximity to the natural environment. We summarize the evidence for associations between exposure to green space and blue space and improvements in health. In contrast, grey space - the urban landscape - largely presents hazards as well as reducing exposure to green and blue space and isolating us from the natural environment. We discuss various hypotheses that might explain why green, blue, and grey space affect health and focus particularly on the importance of the biodiversity hypothesis and the role of microbiota. We discuss possible mechanisms and exposure routes - air, soil, and water. We highlight the problem of exposure assessment, noting that many of our current tools are not fit for the purpose of understanding exposure to green and blue space, aerosols, soils, and water. We briefly discuss possible differences between indigenous perspectives on the nature of our relationship with the environment and the more dominant international-science view. Finally, we present research gaps and discuss future directions, particularly focusing on the ways in which we might - even in the absence of a full understanding of the mechanisms by which blue, green, and grey space affect our health - begin to implement policies to restore some balance to our environment of with the aim of reducing the large global burden of ill health.

Exposure to natural environments during pregnancy and birth outcomes in 11 European birth cohorts

Research suggests that maternal exposure to natural environments (i.e., green and blue spaces) promotes healthy fetal growth. However, the available evidence is heterogeneous across regions, with very few studies on the effects of blue spaces. This study evaluated associations between maternal exposure to natural environments and birth outcomes in 11 birth cohorts across nine European countries. This study, part of the LifeCycle project, was based on a total sample size of 69,683 newborns with harmonised data. For each participant, we calculated seven indicators of residential exposure to natural environments: surrounding greenspace in 100m, 300m, and 500m using Normalised Difference Vegetation Index (NDVI) buffers, distance to the nearest green space, accessibility to green space, distance to the nearest blue space, and accessibility to blue space. Measures of birth weight and small for gestational age (SGA) were extracted from hospital records. We used pooled linear and logistic regression models to estimate associations between exposure to the natural environment and birth outcomes, controlling for the relevant covariates. We evaluated the potential effect modification by socioeconomic status (SES) and region of Europe and the influence of ambient air pollution on the associations. In the pooled analyses, residential surrounding greenspace in 100m, 300m, and 500m buffer was associated with increased birth weight and lower odds for SGA. Higher residential distance to green space was associated with lower birth weight and higher odds for SGA. We observed close to null associations for accessibility to green space and exposure to blue space. We found stronger estimated magnitudes for those participants with lower educational levels, from more deprived areas, and living in the northern European region. Our associations did not change notably after adjustment for air pollution. These findings may support implementing policies to promote natural environments in our cities, starting in more deprived areas.

Exploration of a community pharmacy delivered mobile health intervention to support medication taking for patients with multiple long-term conditions

Introduction

Up to half of people with long-term conditions (LTCs) do not take their medicines as prescribed. Mobile health interventions, such as text messaging, have been shown to have positive impact on medication adherence.1 However, interventions for patients with multiple LTCs are lacking, and there are limited examples of their delivery from community pharmacy settings. We have developed a new intervention which combines a pharmacist consultation and automated two-way text messaging to support medicines taking. This has been developed using peer-reviewed literature and focus groups with patients and healthcare professionals (GPs, pharmacists, nurses). The intervention is tailored to the individual using a questionnaire and delivers content for up to eight LTCs.

Aim

To explore the acceptability of our new intervention with patients.

Methods

The new intervention was delivered to patients in a simulated environment, including a consultation with a pharmacist and two weeks of text messaging. Diary-interviews were used to gather feedback from eight patients, recruited through a public, patient and carer involvement group based at a university. Patients kept a diary during the period of text messaging and follow-up semi-structured interviews were conducted. Interviews were audio recorded and transcribed verbatim for analysis. Transcripts were coded for aspects of the intervention that the patients liked and ideas on how the intervention could be changed, including the impact of delivering the intervention from community pharmacies. Ethical approval for this study was granted by the University of Sunderland Research Ethics Committee.

Results

The intervention had good acceptability with patients. Patients were happy to interact with the text messaging content, including providing information about symptoms of their long-term condition and result of home monitoring. Patients liked that the intervention was linked to a pharmacist consultation, where there were opportunities to identify medication issues which text messaging could not solve. Delivering the intervention from a community pharmacy setting was felt to promote stronger engagement with the text messaging component, including the opportunity to build rapport with the pharmacist who would be overseeing the intervention. The mechanism to monitor medication adherence using two-way text messaging was suggested to be made more streamlined, and patients also wanted more examples of text message responses included in the patient information leaflet for the intervention.

Discussion/Conclusion

We found that our intervention to support medication taking from community pharmacies has initial acceptability with patients. Whilst others have trialled similar technologies from community pharmacies2 our intervention focussed solely on medication taking, and this seemed to result in positive attitudes towards its delivery from community pharmacies. The consultation was found to be an important component alongside the text messaging, how combining digital and non-digital components work together to support medication adherence was a gap highlighted in our previous review of similar interventions.3 Our intervention now requires changes based on the feedback gathered in this study and further testing in a larger and more diverse group.

References

1. Thakkar J, Kurup R, Laba T-L, Santo K, Thiagalingam A, Rodgers A, et al. Mobile Telephone Text Messaging for Medication Adherence in Chronic Disease: A Meta-analysis. JAMA Intern Med. 2016;176:340–9.

2. Cork T, Sanzeri D, Chambers R, Chamber C. Can pharmacists promote self-care using digital technology? Prescriber. 2018;29:21–4.

3. Donovan G, Hall N, Ling J, Smith F, Wilkes S. Influencing medication taking behaviors using automated two-way digital communication: A narrative synthesis systematic review informed by the Behavior Change Wheel. Br J Health Psychol. n/a n/a. https://doi.org/10.1111/bjhp.12580.

Pesticide exposure in New Zealand school-aged children: Urinary concentrations of biomarkers and assessment of determinants

This study aimed to assess pesticide exposure and its determinants in children aged 5-14 years. Urine samples (n = 953) were collected from 501 participating children living in urban areas (participant n = 300), rural areas but not on a farm (n = 76), and living on a farm (n = 125). The majority provided two samples, one in the high and one in the low spraying season. Information on diet, lifestyle, and demographic factors was collected by questionnaire. Urine was analysed for 20 pesticide biomarkers by GC-MS/MS and LC-MS/MS. Nine analytes were detected in > 80% of samples, including six organophosphate insecticide metabolites (DMP, DMTP, DEP, DETP, TCPy, PNP), two pyrethroid insecticide metabolites (3-PBA, trans-DCCA), and one herbicide (2,4-D). The highest concentration was measured for TCPy (median 13 μg/g creatinine), a metabolite of chlorpyrifos and triclopyr, followed by DMP (11 μg/g) and DMTP (3.7 μg/g). Urine metabolite levels were generally similar or low compared to those reported for other countries, while relatively high for TCPy and pyrethroid metabolites. Living on a farm was associated with higher TCPy levels during the high spray season. Living in rural areas, dog ownership and in-home pest control were associated with higher levels of pyrethroid metabolites. Urinary concentrations of several pesticide metabolites were higher during the low spraying season, possibly due to consumption of imported fruits and vegetables. Organic fruit consumption was not associated with lower urine concentrations, but consumption of organic food other than fruit or vegetables was associated with lower concentrations of TCPy in the high spray season. In conclusion, compared to other countries such as the U.S., New Zealand children had relatively high exposures to chlorpyrifos/triclopyr and pyrethroids. Factors associated with exposure included age, season, area of residence, diet, in-home pest control, and pets.

Exposure to atmospheric metals using moss bioindicators and neonatal health outcomes in Portland, Oregon

Studying the impacts of prenatal atmospheric heavy-metal exposure is challenging, because biological exposure monitoring does not distinguish between specific sources, and high-resolution air monitoring data is lacking for heavy metals. Bioindicators - animal or plant species that can capture environmental quality - are a low-cost tool for evaluating exposure to atmospheric heavy-metal pollution that have received little attention in the public-health literature. We obtained birth records for Portland, Oregon live births (2008-2014) and modeled metal concentrations derived from 346 samples of moss bioindicators collected in 2013. Exposure estimates were assigned using mother's residential address at birth for six metals with known toxic and estrogenic effects (arsenic, cadmium, chromium, cobalt, nickel, lead). Associations were evaluated for continuous (cts) and quartile-based (Q) metal estimates and three birth outcomes (preterm birth (PTB; <37 weeks)), very PTB (vPTB; <32 weeks), small for gestational age (SGA; 10th percentile of weight by age and sex)) using logistic regression models with adjustment for demographic characteristics, and stratified by maternal race. Chromium and cobalt were associated with increased odds of vPTB (chromium - odds ratio (OR)_cts = 1.09, 95% CI: 1.00, 1.17; cobalt - OR_Q4vsQ1 = 1.33, 95% CI: 1.03, 1.71). Cobalt, chromium and cadmium were significantly associated with odds of SGA, although the direction of association differed by metal (cobalt - OR_cts = 1.04, 95% CI: 1.01, 1.07; chromium - OR_Q3vsQ1 = 0.91, 95% CI: 0.83, 0.99; cadmium - OR_cts = 0.96, 95% CI: 0.93, 1.00). In stratified analyses, odds of SGA were significantly different among non-white mothers compared to white mothers with exposure to chromium, cobalt, lead and nickel. This novel application of a moss-based exposure metric found that exposure to some atmospheric metals is associated with adverse birth outcomes. These findings are consistent with previous literature and suggest that moss bioindicators are a useful complement to traditional exposure-assessment methods.

A qualitative synthesis of pharmacist, other health professional and lay perspectives on the role of community pharmacy in facilitating care for people with long-term conditions

BACKGROUND

There is increasing interest in an enhanced role for community pharmacy (CP) in facilitating care for people with long-term conditions (LTCs). It is important to understand the perspectives of stakeholders in order to identify key issues that may impact on future development of the role and related services.

OBJECTIVES

Explore pharmacist, other health professional and lay perspectives on the role of CP in facilitating care for people with LTCs.

METHODS

Synthesis of qualitative research from UK based studies published between 2007 and January 2017 using a meta-ethnographic interpretative approach.

RESULTS

Variation in the conceptualisation of the role of CP in facilitating the care of people with LTCs was apparent across and within lay and health professional accounts. Despite evidence of positive attitudes and a culture amenable to change, there remains a lack of clarity about the existing and potential role of the pharmacist in this area. A theoretical framework is proposed that highlights the dynamic nature of the process involved in the development of lay and health professionals' understanding of the role and engagement with services. Influences on this process include experience and perceived need, service operationalisation, and ongoing developments within wider healthcare policy and commercial environments. Perceived integration with existing professional and peer support structures, views about traditional medical hierarchies and concerns about potential duplication are important influences on the value attributed to the role of CP and the services provided.

CONCLUSIONS

There is acknowledged potential for an extended role in CP to support the care of people with LTCs. To ensure the likelihood of successful engagement with patients and positive health outcomes, developments should acknowledge influences within and beyond the CP setting. Potential overlap with other healthcare services should be explicitly addressed, ensuring this is framed and delivered as valued reinforcement with clearly defined boundaries of responsibility.

Computational modeling of airway and pulmonary vascular structure and function: development of a "lung physiome"

Computational models of lung structure and function necessarily span multiple spatial and temporal scales, i.e., dynamic molecular interactions give rise to whole organ function, and the link between these scales cannot be fully understood if only molecular or organ-level function is considered. Here, we review progress in constructing multiscale finite element models of lung structure and function that are aimed at providing a computational framework for bridging the spatial scales from molecular to whole organ. These include structural models of the intact lung, embedded models of the pulmonary airways that couple to model lung tissue, and models of the pulmonary vasculature that account for distinct structural differences at the extra- and intra-acinar levels. Biophysically based functional models for tissue deformation, pulmonary blood flow, and airway bronchoconstriction are also described. The development of these advanced multiscale models has led to a better understanding of complex physiological mechanisms that govern regional lung perfusion and emergent heterogeneity during bronchoconstriction.

Consumer Willingness to Pay for a Naturally Decay-Resistant Wood Product

Chromated copper arsenate (CCA) is the most widely used chemical wood preservative in the United States. Concerns about the safety of CCA led to an agreement between the Environmental Protection Agency and the wood treatment industry to withdraw CCA for nonindustrial uses by the end of 2003. In light of the publicity surrounding the withdrawal of CCA, this article evaluates consumers' willingness to pay a premium for products manufactured from naturally decay-resistant wood as opposed to chemically treated wood. We use a national contingent valuation survey to quantify consumer willingness to pay for a children's play structure made from Alaska yellow-cedar, as opposed to an identical play structure made from southern pine treated with ammonial copper quaternary, the likely replacement for CCA. Respondents' estimated mean willingness to pay for the Alaska yellow-cedar play structure is $2,013, compared to $1,000 for the treated southern pine structure. This study shows that manufacturers of products made from naturally decay-resistant wood may be able to capture a substantial premium for their products. West. J. Appl. For. 19(3):160–164.

Challenges for continuing education of public health nurses in Florida

Perceived continuing education needs among public health nurses at the staff and supervisory levels were investigated. A questionnaire was adapted for each and administered at participating county public health units. Results indicated a high level of agreement between staff nurses and supervisors. Further analysis of the data suggested a relationship between the nurses' perception of continuing education needs and the realities of their nursing practice. Public health nurses, educators, and administrators face the challenge of refocusing continuing education needs and activities on the broad scope of this area of specialty.

Analysis of the Development Test of Visual Perception and the Motor-Free Visual Perception Test

To identify children with learning problems and to compare test results, 28 kindergarten children were tested with the Developmental Test of Visual Perception and the Motor-free Visual Perception Test. The tests identified some children already noted by the teacher to exhibit characteristics of learning difficulty, failed to confirm the teacher's judment in others, and identified some children with previously undetected difficulties. Basic differences in the two tests are reported.