Overcoming Systemic Barriers Preventing Healthy Urban Development in the UK: Main Findings from Interviewing Senior Decision-Makers During a 3-Year Planetary Health Pilot

This paper sets out the main findings from two rounds of interviews with senior representatives from the UK’s urban development industry: the third and final phase of a 3-year pilot, Moving Health Upstream in Urban Development’ (UPSTREAM). The project had two primary aims: firstly, to attempt to value economically the health cost-benefits associated with the quality of urban environments and, secondly, to interview those in control of urban development in the UK in order to reveal the potential barriers to, and opportunities for, the creation of healthy urban environments, including their views on the use of economic valuation of (planetary) health outcomes. Much is known about the ‘downstream’ impact of urban environments on human and planetary health and about how to design and plan healthy towns and cities (‘midstream’), but we understand relatively little about how health can be factored in at key governance tipping points further ‘upstream’, particularly within dominant private sector areas of control (e.g. land, finance, delivery) at sub-national level. Our findings suggest that both public and private sector appeared well aware of the major health challenges posed by poor-quality urban environments. Yet they also recognized that health is not factored adequately into the urban planning process, and there was considerable support for greater use of non-market economic valuation to help improve decision-making. There was no silver bullet however: 110 barriers and 76 opportunities were identified across a highly complex range of systems, actors and processes, including many possible points of targeted intervention for economic valuation. Eight main themes were identified as key areas for discussion and future focus. This findings paper is the second of two on this phase of the project: the first sets out the rationale, approach and methodological lessons learned.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11524-021-00537-y.     

The public health emergency of climate change: how/are Canadian post-secondary public health sciences programs responding?

ObjectiveThe Intergovernmental Panel on Climate Change recently issued a statement that the fate of human society and human health is at serious risk of catastrophic impacts unless we take bold action to keep global warming under 1.5 °C. In 2015, the Canadian Public Health Association noted emerging efforts to embrace intersectoral approaches to global change in public health research and practice. In this study, we question the extent to which Canadian Graduate Public Health Sciences Programs have kept pace with these efforts to see climate change surface as a new frontier for training the next generation of researchers and practitioners.MethodsSemi-structured interviews (19) were conducted with Department Heads (or equivalents) of graduate-level Public Health Sciences Programs at 15 Canadian universities concerning the place of climate change in their respective curricula. Interviews were designed to elicit participants’ institutional perspectives on the importance of climate change in the Public Health Sciences and identify perceived challenges and opportunities.ResultsDespite wide recognition among participants that climate change is a public health “crisis”, very few reported having substantive curricular engagement on the topic. Key challenges identified were lack of resources, organizational issues, and political barriers. Key opportunities to adapt curricula to address this new frontier in Public Health were faculty interest and expertise, cross-disciplinary collaboration, and pressure from the institution.ConclusionOur findings provide evidence for post-secondary Public Health Sciences Programs to understand the need to address their own sluggishness when what is needed are bold, even radical, shifts to existing curricula.     

Achieving the SDGs: Evaluating indicators to be used to benchmark and monitor progress towards creating healthy and sustainable cities

In 2016, the World Health Organization declared that ‘Health is one of the most effective markers of any city’s successful sustainable development’ (World Health Organisation, 2016). With estimates that around 6.7 billion people will live in cities by 2050, 21^st century city planning decisions will play a critical role in achieving the United Nations (UN) Sustainable Development Goals (SDGs). They will determine the city structure and access to health-enhancing (or health-damaging) urban environments, and ultimately lifestyle choices that impact both individual and planetary health. Benchmarking, monitoring and evaluating city planning policies and interventions is therefore critical to optimise urban outcomes. In 2017, the UN adopted a global SDG indicator framework, calling for complementary national and regional indicators to be collected by member countries. UN Habitat has also developed an indicator action framework specifically for cities. This paper examined the extent to which the UN indicators will help cities evaluate their efforts to deliver sustainability and health outcomes. It identified inconsistencies between the two UN indicator frameworks. Many of the SDG indicators assess outcomes, rather than the comprehensive and integrated ‘upstream’ policies and interventions required to deliver outcomes on-the-ground. Conversely, the UN Habitat framework incorporates intervention indicators, but excludes health outcome indicators. A more comprehensive approach to benchmarking, monitoring and evaluating policies designed to achieve healthy and sustainable cities and assessing spatial inequities is proposed.     

Ten years since the crises in Syria: lessons for planetary and public health

Climate scientists have attributed the war in Syria to persistent droughts caused by damming of rivers and growing aridity due to climate change. As result of the war, there has been widespread migration, hunger, malnutrition, and a collapse of public health systems. While many climate researchers question the direct link of climate variability to civil unrest, there is no doubt that mitigating and reversing Syria’s environmental degradation, and reviving food security and public health systems will play an important role in avoiding future unrest in the region.     

Seeking or contributing? Evidence of knowledge sharing behaviours in promoting patients’ perceived value of online health communities

BackgroundHealth knowledge, as an important resource of online health communities (OHCs), attracts users to engage in OHCs and improve the traffics within OHCs, thereby promoting the development of OHCs. Seeking and contributing health knowledge are basic activities in OHCs and are helpful for users to solve their health‐related problems, improve their health conditions and thus influence their evaluation of OHCs (ie perceived value of OHCs). However, how do patients’ health knowledge seeking and health knowledge contributing behaviours together with other factors influence their perceived value of OHCs? We still have little knowledge.ObjectiveIn order to address the above gap, we root the current study in social cognitive theory and prior related literature on health knowledge sharing in OHCs and patients’ perceived value. We treat health knowledge seeking and health knowledge contributing behaviours as behavioural factors and structural social capital as an environmental factor and explore their impacts on patients’ perceived value of OHCs.DesignWe have built a theoretical model composed of five hypotheses. We have designed a questionnaire composed of four key constructs and then collected data via an online survey.Setting and participantsWe have distributed the questionnaire in two Chinese OHCs. We obtained a sample of 352 valid responses that were completed by patients having a variety of conditions.ResultsThe empirical results indicate that health knowledge seeking and health knowledge contributing have positive impacts on patients’ perceived value of OHCs. The impact of health knowledge seeking on patients’ perceived value of OHCs is greater than the impact of health knowledge contributing. In addition, structural social capital moderates the effects of health knowledge seeking and health knowledge contributing on patients’ perceived value of OHCs. It weakens the effect of health knowledge seeking but enhances the effect of health knowledge contributing on patients’ perceived value of OHCs.ConclusionsThese findings contribute to the literature on patients’ perceived value of OHCs and on the role of structural social capital in OHCs. For OHC managers, they should provide their users more opportunities to seek or contribute health knowledge in their communities.     

Consequences of Paternal Nutrition on Offspring Health and Disease

It is well established that the maternal diet during the periconceptional period affects the progeny’s health. A growing body of evidence suggests that the paternal diet also influences disease onset in offspring. For many years, sperm was considered only to contribute half of the progeny’s genome. It now appears that it also plays a crucial role in health and disease in offspring’s adult life. The nutritional status and environmental exposure of fathers during their childhood and/or the periconceptional period have significant transgenerational consequences. This review aims to describe the effects of various human and rodent paternal feeding patterns on progeny’s metabolism and health, including fasting or intermittent fasting, low-protein and folic acid deficient food, and overnutrition in high-fat and high-sugar diets. The impact on pregnancy outcome, metabolic pathways, and chronic disease onset will be described. The biological and epigenetic mechanisms underlying the transmission from fathers to their progeny will be discussed. All these data provide evidence of the impact of paternal nutrition on progeny health which could lead to preventive diet recommendations for future fathers.     

Adopting a “Compound” Exposome Approach in Environmental Aging Biomarker Research: A Call to Action for Advancing Racial Health Equity

Background: In June 2020, the National Academies of Sciences, Engineering, and Medicine hosted a virtual workshop focused on integrating the science of aging and environmental health research. The concurrent COVID-19 pandemic and national attention on racism exposed shortcomings in the environmental research field’s conceptualization and methodological use of race, which have subsequently hindered the ability of research to address racial health disparities. By the workshop’s conclusion, the authors deduced that the utility of environmental aging biomarkers—aging biomarkers shown to be specifically influenced by environmental exposures—would be greatly diminished if these biomarkers are developed absent of considerations of broader societal factors—like structural racism—that impinge on racial health equity.Objectives: The authors reached a post-workshop consensus recommendation: To advance racial health equity, a “compound” exposome approach should be widely adopted in environmental aging biomarker research. We present this recommendation here.Discussion: The authors believe that without explicit considerations of racial health equity, people in most need of the benefits afforded by a better understanding of the relationships between exposures and aging will be the least likely to receive them because biomarkers may not encompass cumulative impacts from their unique social and environmental stressors. Employing an exposome approach that allows for more comprehensive exposure–disease pathway characterization across broad domains, including the social exposome and neighborhood factors, is the first step. Exposome-centered study designs must then be supported with efforts aimed at increasing the recruitment and retention of racially diverse study populations and researchers and further “compounded” with strategies directed at improving the use and interpretation of race throughout the publication and dissemination process. This compound exposome approach maximizes the ability of our science to identify environmental aging biomarkers that explicate racial disparities in health and best positions the environmental research community to contribute to the elimination of racial health disparities. https://doi.org/10.1289/EHP8392     

Enhancing Behavior Change Skills in Health Extension Workers in Ethiopia: Evaluation of an Intervention to Improve Maternal and Infant Nutrition

Maternal and infant nutrition are problematic in areas of Ethiopia. Health extension workers (HEWs) work in Ethiopia’s primary health care system, increasing potential health service coverage, particularly for women and children, providing an opportunity for health improvement. Their roles include improving maternal and infant nutrition, disease prevention, and health education. Supporting HEWs’ practice with ‘non-clinical’ skills in behavior change and health communication can improve effectiveness. This intervention study adapted and delivered a UK-developed training intervention for Health Extension Workers (HEWs) working with the United Nations World Food Programme in Ethiopia. The intervention included communication and behavioral training adapted with local contextual information. Mixed methods evaluation focused on participants’ reaction to training, knowledge, behavior change, and skills use. Overall, 98 HEWs were trained. The intervention was positively received by HEWs. Pre-post evaluations of communication and behavior change skills found a positive impact on HEW skills, knowledge, and motivation to use skills (all p < 0.001) to change women’s nutritional behavior, also demonstrated in role-play scenarios. The study offered substantial learning about intervention delivery. Appropriate cultural adaptation and careful consideration of assessment of psychological constructs are crucial for future delivery.     

A Health Impact Assessment of California’s Proposed Cap-and-Trade Regulations

Objectives. To identify unintended health effects of California’s controversial cap-and-trade regulations and establish health-promoting policy recommendations, we performed a health impact assessment.Methods. We used literature reviews, public data, and local health surveys to qualitatively assess potential health risks and benefits related to changes in employment and income, energy costs, effects of emission offset projects, and cobenefits from the allocation of program revenue. We examined case studies from various communities to find existing social, economic, and environmental health conditions.Results. We found that policy implementation will minimally impact job creation (< 0.1% change) and that health effects from job sector shifts are unlikely. Fuel prices may increase (0%–11%), and minor negative health effects could accrue for some low-income households.Conclusions. Offset projects would likely benefit environmental health, but more research is needed. Allocating some program revenue for climate change adaptation and mitigation would have substantial health benefits. Health impact assessment is a useful tool for health agencies to engage in policy discussions that typically fall outside public health. Our results can inform emission reduction strategies and cap-and-trade policy at the federal level.Climate change is expected to substantially increase disease burden in California. The projected health impacts in California from climate change include increased exposure to heat and extreme weather events such as floods and storms; changes in the frequency and distribution of vector-borne, food-borne, and waterborne diseases; increases in illnesses related to air pollution and ultraviolet radiation exposure; food and economic insecurity and migration and social disruptions; and consequent mental health effects.1–3The California state legislature passed Assembly Bill 32, The Global Warming Solutions Act of 2006 (AB 32), to reduce greenhouse gas emissions statewide to 1990 levels by the year 2020. AB 32 allowed the implementation of a cap-and-trade program and other complementary measures to reach the emission reduction goal. The legislation also included explicit provisions to ensure that regulatory goals would not disproportionately affect disadvantaged communities, would consider public health impacts, and would direct investments to California’s most disadvantaged communities.4 The California Department of Public Health (CDPH) undertook a health impact assessment (HIA) to describe the potential health effects of a cap-and-trade program, including recommendations to minimize health risks and maximize potential health cobenefits. An HIA is

a combination of procedures, methods and tools by which a policy programme or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population.^5(p4)

Based on potential health impacts, an HIA should propose policy adjustments to minimize the negative and maximize the positive health impacts.California’s cap-and-trade program is a market-based approach to control emissions using a variety of economic incentives to achieve greenhouse gas emission reductions. Although a cap-and-trade program would account for less than 20% of all emission reductions under AB 32,6 the cap-and-trade program in California is highly controversial. Many environmental justice advocates have remained critical of market-based emission reduction strategies, particularly because of the potential for variable reductions in copollutant emissions in specific locations and the development of small geographic areas with relatively high concentrations of particulate pollution within the larger pollution control region. Although cap-and-trade is being implemented within the context of existing air regulations that limit many increases in toxic air contaminants and regulated pollutants, differing views exist on the role of cap-and-trade as a tool for broader pollution control and cap-and-trade’s potential to increase pollution in some communities.7–10In fall 2009 the Climate Action Team Public Health Workgroup decided that an HIA of cap-and-trade in California would be useful and relevant.11,12 The HIA was a voluntary, nonregulatory assessment carried out in parallel to the regulatory processes of the California Air Resources Board (CARB), the agency implementing AB 32. The HIA, led by CDPH staff, was the first HIA led by a state agency in California. HIA stakeholders included environmental, economic, health, and industry professionals.CDPH assessed the potential health effects that may stem from changes in employment, energy costs, and community investments funded by cap-and-trade revenue and various offset projects. Although many environmental justice stakeholders were most concerned about local air impacts, the CDPH HIA did not assess local health impacts related to changes in emissions. As part of the regulatory process, CARB was required to assess changes in copollutant air emissions with regard to the cap-and-trade rule.13 Thus, CPDH did not quantitatively assess air emissions but focused its resources on assessing other health pathways.     

Integrating climate change adaptation into public health practice: using adaptive management to increase adaptive capacity and build resilience

Background: Climate change is expected to have a range of health impacts, some of which are already apparent. Public health adaptation is imperative, but there has been little discussion of how to increase adaptive capacity and resilience in public health systems.Objectives: We explored possible explanations for the lack of work on adaptive capacity, outline climate–health challenges that may lie outside public health’s coping range, and consider changes in practice that could increase public health’s adaptive capacity.Methods: We conducted a substantive, interdisciplinary literature review focused on climate change adaptation in public health, social learning, and management of socioeconomic systems exhibiting dynamic complexity.Discussion: There are two competing views of how public health should engage climate change adaptation. Perspectives differ on whether climate change will primarily amplify existing hazards, requiring enhancement of existing public health functions, or present categorically distinct threats requiring innovative management strategies. In some contexts, distinctly climate-sensitive health threats may overwhelm public health’s adaptive capacity. Addressing these threats will require increased emphasis on institutional learning, innovative management strategies, and new and improved tools. Adaptive management, an iterative framework that embraces uncertainty, uses modeling, and integrates learning, may be a useful approach. We illustrate its application to extreme heat in an urban setting.Conclusions: Increasing public health capacity will be necessary for certain climate–health threats. Focusing efforts to increase adaptive capacity in specific areas, promoting institutional learning, embracing adaptive management, and developing tools to facilitate these processes are important priorities and can improve the resilience of local public health systems to climate change.     

Toward Better Estimates of the Cost of Climate Change Mitigation: Guidelines for Studying Potential Health Benefits

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Worldwide, efforts to mitigate climate change through reduction of greenhouse gas emissions are falling short of what is needed to meet ambitious international goals such as the Paris Agreement.1 Research estimating the health effects of mitigation (HEM) indicates that climate change mitigation activities could have substantial health co-benefits that partially or completely offset the economic costs of mitigation. Yet few HEM findings have been incorporated into cost estimates of mitigation activities, making the activities appear unacceptably expensive to policymakers.2 The authors of a recent commentary in Environmental Health Perspectives present guidelines for conducting and reporting HEM studies so that the results are comparable and responsive to stakeholder priorities and that health benefits are thus more often considered in cost estimates.3Open in a separate windowClimate change mitigation activities often produce health co-benefits in addition to simply reducing greenhouse gas emissions. For example, installing wind power facilities to replace coal-fired power plants means fewer hazardous air pollutants in regional and local air. That could result in fewer hospitalizations for respiratory diseases. Image: © iStockphoto/Baxternator.HEM research has often operated in a silo, not effectively engaging stakeholders in the research process. That could be one reason for the low uptake of their recommendations by policy makers, according to lead commentary author Jeremy Hess, a professor in the University of Washington’s Department of Environmental and Occupational Health Sciences. The University of Washington, the World Health Organization, and the Wellcome Trust’s Our Planet, Our Health funding foundation jointly convened a workshop in London to develop consistent guidelines for planning and reporting HEM research. Among these guidelines were recommendations for how to better engage stakeholders in the research process—ultimately leading to increased uptake when developing mitigation policies.“Ultimately, HEM research aims to inform policy decisions,” says Hess. “Without knowing the priorities of policy makers and how they might use the estimates, such research is at risk of being ignored. Dialogues between policy makers and scientists take time, and such processes are often not supported as part of research activities.”Led by Hess and Kristie Ebi—also a professor of Environmental and Occupational Health Sciences at the University of Washington—the team conducted a modified Delphi process to reach preliminary consensus on issues related to engaging stakeholders before scoping projects, modeling approaches to use, choices about model parameters, and communicating results. The outcome was then discussed in depth at the expert workshop.At the end of the process, the authors developed a list of specific recommendations to optimize stakeholder engagement and study design and reporting. They encouraged the creation of trans- and interdisciplinary stakeholder teams to more thoughtfully develop research questions and anticipate unforeseen consequences. They also recommended ways to ensure future HEM studies yield high-quality results, including best practices for describing the study population and health metrics used, reporting counterfactual scenarios, accounting for different levels of policy uptake, and sharing data.“As the paper notes, a wide range of methods have been used to evaluate ancillary health benefits and costs of technologies and policies to reduce carbon emissions,” says Tracey Holloway, a professor of environmental studies at the University of Wisconsin–Madison who was not involved with the paper. “With so many different study design approaches, it can be difficult to compare study results in an ‘apples to apples’ manner. This study lays a roadmap for future work to enhance the rigor, comparability, and relevance to decision makers.”“I would have loved to see a few specific examples—case studies to show the recommendations in practice,” Holloway adds. “Sharing a few concrete examples would clarify some of the points in the paper, especially to readers who may not have thought about the nuts and bolts of studies like this.”Despite the emphasis on engaging stakeholders and developing more standardized approaches, that result is not assured, says Michael Brauer, a professor of occupational and environmental health at the University of British Columbia who also was not an author of the commentary. “The goal of standardization as a means to hopefully increase uptake of these kinds of analyses for policy development and implementation is certainly worthwhile,” Brauer says. “But even if this guidance is followed, it certainly doesn’t guarantee that there will be more use of [HEM] analyses in policy prioritization.”That is nevertheless the ultimate aim of the guidance. “At the end of the day, we hope these guidelines will lead to more widespread, rapid implementation of climate change mitigation, which will be good for health,” says Hess. “It will help reduce the risks of dangerous climate change in the long run and will produce a raft of important health benefits starting almost immediately.”     

One health disparities and COVID-19

 The global impact of the COVID-19 pandemic has disproportionately affected some communities and populations more than others. We propose that an interdisciplinary framework of ‘One Health Disparities’ advances understanding of the social and systemic issues that drive COVID-19 in vulnerable populations. One Health Disparities integrates the social environment with One Health perspectives on the interconnectedness of human, animal, and environmental health. To apply this framework, we consider One Health Disparities that emerge in three key components of disease transmission: exposure, susceptibility, and disease expression. Exposure disparities arise through variation in contact with COVID-19’s causative agent, SARS-CoV-2. Disparities in susceptibility and disease expression also exist; these are driven by biological and social factors, such as diabetes and obesity, and through variation in access to healthcare. We close by considering how One Health Disparities informs understanding of spillback into new animal reservoirs, and what this might mean for further human health disparities.Lay summaryOne Health focuses on interconnections between human, animal, and environmental health. We propose that social environments are also important to One Health and help illuminate disparities in the coronavirus pandemic, including its origins, transmission and susceptibility among humans, and spillback to other species. We call this framework One Health Disparities.     

The Application of ‘Elite Interviewing’ Methodology in Transdisciplinary Research: a Record of Process and Lessons Learned during a 3-Year Pilot in Urban Planetary Health Research

This paper sets out the rationale and process for the interviewing methodology utilized during a 3-year research pilot, ‘Moving Health Upstream in Urban Development’ (UPSTREAM). The project had two primary aims: firstly, to attempt to value economically the health cost benefits associated with the quality of urban environments and secondly, to engage with those in control of urban development in the UK in order to determine what are the barriers to and opportunities for creating healthy urban environments, including those identified through the utilisation of economic valuation. Engagement at senior level with those who have most control over key facets of planning and development implementation—such as land disposal, investment, development delivery and planning permission—was central to the approach, which encompassed the adoption of ‘elite interviewing’, a method developed in the USA in the 1950s and used in the political sciences but relatively unutilized in the health and environmental sciences [¹]. Two rounds of semi-structured interviews were undertaken with 15 senior decision-makers from the UK’s main urban development delivery agencies, both public and private. The ‘elite interviewing’ approach successfully enabled the UPSTREAM project to capture and analyse the information received from the interviewees, all of whom held influential or leadership posts in organisations that are important actors in the process of planning, developing and constructing the built environment in the UK. Having academic and practitioner research leads on an equal footing created some minor tensions, but it also appeared to strengthen the rigor of the approach through a broad knowledge of context ‘in-house’. This form of co-production at times challenged academic traditions in qualitative analysis, but it also appeared to build trust with interviewees and provided greater clarity of the real-world context under investigation. Findings from this study are written up in a separate paper.     

Global climate change and children's health: threats and strategies for prevention

Background

Global climate change will have multiple effects on human health. Vulnerable populations—children, the elderly, and the poor—will be disproportionately affected.

Objective

We reviewed projected impacts of climate change on children’s health, the pathways involved in these effects, and prevention strategies.

Data sources

We assessed primary studies, review articles, and organizational reports.

Data synthesis

Climate change is increasing the global burden of disease and in the year 2000 was responsible for > 150,000 deaths worldwide. Of this disease burden, 88% fell upon children. Documented health effects include changing ranges of vector-borne diseases such as malaria and dengue; increased diarrheal and respiratory disease; increased morbidity and mortality from extreme weather; changed exposures to toxic chemicals; worsened poverty; food and physical insecurity; and threats to human habitation. Heat-related health effects for which research is emerging include diminished school performance, increased rates of pregnancy complications, and renal effects. Stark variation in these outcomes is evident by geographic region and socioeconomic status, and these impacts will exacerbate health disparities. Prevention strategies to reduce health impacts of climate change include reduction of greenhouse gas emissions and adaptation through multiple public health interventions.

Conclusions

Further quantification of the effects of climate change on children’s health is needed globally and also at regional and local levels through enhanced monitoring of children’s environmental health and by tracking selected indicators. Climate change preparedness strategies need to be incorporated into public health programs.     

Women’s Health and the Affordable Care Act: High Hopes Versus Harsh Realities?

Our population-based survey of 1078 randomly sampled US women, aged 18 to 55 years, sought to characterize their understanding of and attitudes toward the Affordable Care Act (ACA). Most women, especially socially disadvantaged groups, had negative or uncertain attitudes toward the ACA and limited understanding of its health benefits, including its relevance for their own health service coverage and utilization. Our findings are important for continued research, policy, and practice, with implications for whether, when, and how improved coverage will translate to improved access and outcomes for US women.Women’s health clinicians, researchers, and policymakers are hopeful that expanding health care coverage under the Patient Protection and Affordable Care Act (ACA)1 will improve the health of US women. By requiring coverage, increasing access to affordable health plans, incentivizing utilization of high-value services, establishing benefit mandates, and reducing cost sharing, the ACA is expected to improve health outcomes and reduce health disparities for women. Since ACA implementation began, however, it has become clear that the public’s participation in its programs and benefits is compromised by widespread confusion.2–6 Recognizing that the ACA can only have an impact on women’s health (individual and population) if women are aware of available benefits and act upon them,7–9 we conducted a study to examine women’s understanding of and attitudes toward the ACA. Specifically, we sought to determine (1) whether women were aware and approved of the ACA and the women’s health benefits attributable to it, (2) whether women expected their coverage of women’s health services and subsequent service utilization to change as a result of the ACA, and (3) whether women’s awareness and attitudes differed across sociodemographic groups.     

Reducing Health Risks from Indoor Exposures in Rapidly Developing Urban China

Background: Over the past two decades there has been a large migration of China’s population from rural to urban regions. At the same time, residences in cities have changed in character from single-story or low-rise buildings to high-rise structures constructed and furnished with many synthetic materials. As a consequence, indoor exposures (to pollutants with outdoor and indoor sources) have changed significantly.Objectives: We briefly discuss the inferred impact that urbanization and modernization have had on indoor exposures and public health in China. We argue that growing adverse health costs associated with these changes are not inevitable, and we present steps that could be taken to reduce indoor exposures to harmful pollutants.Discussion: As documented by China’s Ministry of Health, there have been significant increases in morbidity and mortality among urban residents over the past 20 years. Evidence suggests that the population’s exposure to air pollutants has contributed to increases in lung cancer, cardiovascular disease, pulmonary disease, and birth defects. Whether a pollutant has an outdoor or an indoor source, most exposure to the pollutant occurs indoors. Going forward, indoor exposures can be reduced by limiting the ingress of outdoor pollutants (while providing adequate ventilation with clean air), minimizing indoor sources of pollutants, updating government policies related to indoor pollution, and addressing indoor air quality during a building’s initial design.Conclusions: Taking the suggested steps could lead to significant reductions in morbidity and mortality, greatly reducing the societal costs associated with pollutant derived ill health.     

Australian Consumers Are Willing to Pay for the Health Star Rating Front-of-Pack Nutrition Label

The Australia and New Zealand Ministerial Forum on Food Regulation has supported the recommendations set out in the 2019 Health Star Rating System Five Year Review Report. Specifically, the forum supported, in principle, Recommendation 9, to mandate the Health Star Rating if clear uptake targets were not achieved while the system is voluntary. Given that mandatory labelling is being considered, it is important to investigate how much consumers value the Health Star Rating in order to understand potential consumer uptake and inform industry. The aim of this study was to assess consumers’ valuation of the Health Star Rating system by analysing their willingness to pay for a packaged food product with the Health Star Rating label, utilising a double-bounded dichotomous choice contingent valuation approach. The results indicate that almost two-thirds of Australian household grocery shoppers were willing to pay more for a product with the Health Star Rating, on average up to an additional 3.7% of the price of the product. However, public health nutrition benefits associated with consumers’ willingness to pay more for products with the Health Star Rating is currently limited by the lack of guarantee of the systems’ accuracy. Given consumer support, a well validated and comprehensive Health Star Rating labelling system can potentially improve health outcomes, cost effectiveness and reduce environmental impacts.     

Ten Years of Addressing Children’s Health through Regulatory Policy at the U.S. Environmental Protection Agency

Background

Executive Order (EO) 13045, Protection of Children From Environmental Health Risks and Safety Risks, directs each federal agency to ensure that its policies, programs, activities, and standards address disproportionate environmental health and safety risks to children.

Objectives

We reviewed regulatory actions published by U.S. Environmental Protection Agency (EPA) in the Federal Register from April 1998 through December 2006 to evaluate applicability of EO 13045 to U.S. EPA actions and consideration of children’s health issues in U.S. EPA rulemakings.

Discussion

Although virtually all actions discussed EO 13045, fewer than two regulations per year, on average, were subject to the EO requirement to evaluate children’s environmental health risks. Nonetheless, U.S. EPA considered children’s environmental health in all actions addressing health or safety risks that may disproportionately affect children.

Conclusion

The EO does not apply to a broad enough set of regulatory actions to ensure protection of children’s health and safety risks, largely because of the small number of rules that are economically significant. However, given the large number of regulations that consider children’s health issues despite not being subject to the EO, other statutory requirements and agency policies reach a larger set of regulations to ensure protection of children’s environmental health.     

Toward the Assessment of Scientific and Public Health Impacts of the National Institute of Environmental Health Sciences Extramural Asthma Research Program Using Available Data

Background

In the past 15 years, asthma prevalence has increased and is disproportionately distributed among children, minorities, and low-income persons. The National Institute of Environmental Health Sciences (NIEHS) Division of Extramural Research and Training developed a framework to measure the scientific and health impacts of its extramural asthma research to improve the scientific basis for reducing the health effects of asthma.

Objectives

Here we apply the framework to characterize the NIEHS asthma portfolio’s impact in terms of publications, clinical applications of findings, community interventions, and technology developments.

Methods

A logic model was tailored to inputs, outputs, and outcomes of the NIEHS asthma portfolio. Data from existing National Institutes of Health (NIH) databases are used, along with publicly available bibliometric data and structured elicitation of expert judgment.

Results

NIEHS is the third largest source of asthma-related research grant funding within the NIH between 1975 and 2005, after the National Heart, Lung, and Blood Institute and the National Institute of Allergy and Infectious Diseases. Much of NIEHS-funded asthma research focuses on basic research, but results are often published in journals focused on clinical investigation, increasing the likelihood that the work is moved into practice along the “bench to bedside” continuum. NIEHS support has led to key breakthroughs in scientific research concerning susceptibility to asthma, environmental conditions that heighten asthma symptoms, and cellular mechanisms that may be involved in treating asthma.

Conclusions

If gaps and limitations in publicly available data receive adequate attention, further linkages can be demonstrated between research activities and public health improvements. This logic model approach to research impact assessment demonstrates that it is possible to conceptualize program components, mine existing databases, and begin to show longer-term impacts of program results. The next challenges will be to modify current data structures, improve the linkages among relevant databases, incorporate as much electronically available data as possible, and determine how to improve the quality and health impact of the science that we support.     

The environmental and health impacts of tobacco agriculture,cigarette manufacture and consumption

The health consequences of tobacco use are well known, but less recognized are the significant environmental impacts of tobacco production and use. The environmental impacts of tobacco include tobacco growing and curing; product manufacturing and distribution; product consumption; and post-consumption waste. The World Health Organization’s Framework Convention on Tobacco Control addresses environmental concerns in Articles 17 and 18, which primarily apply to tobacco agriculture. Article 5.3 calls for protection from policy interference by the tobacco industry regarding the environmental harms of tobacco production and use. We detail the environmental impacts of the tobacco life-cycle and suggest policy responses.