Publications by authors named "Lora E Fleming"

207 Publications

Environmental and human health impacts of cruise tourism: A review.

Mar Pollut Bull 2021 Sep 28;173(Pt A):112979. Epub 2021 Sep 28.

European Centre for Environment and Human Health, University of Exeter Medical School, Cornwall TR1 3HD, UK. Electronic address:

The intensive growth of cruise tourism worldwide during recent decades is leading to growing concerns over the sector's global environmental and health impacts. This review combines for the first time various sources of information to estimate the magnitude of the cruise industry's environmental and public health footprints. This research shows that cruising, despite technical advances and some surveillance programmes, remains a major source of air, water (fresh and marine) and land pollution affecting fragile habitats, areas and species, and a potential source of physical and mental human health risks. Health risks impact both the people on board (crew and passengers) and on land (workers of shipyards where cruise ships are dismantled and citizens inhabiting cities with cruise ports and shipyards). In this context, we argue that the cruise industry should be held accountable with more monitoring and regulation to prevent or minimize the growing negative environmental and human health impacts.
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http://dx.doi.org/10.1016/j.marpolbul.2021.112979DOI Listing
September 2021

Single-use plastic and COVID-19 in the NHS: Barriers and opportunities.

J Public Health Res 2021 Aug 4. Epub 2021 Aug 4.

University of Exeter Business School, Penryn Campus, Cornwall.

Background: Single-use personal protective equipment (PPE) has been essential to protect healthcare workers during the COVID-19 pandemic. However, intensified use of PPE could counteract the previous efforts made by the UK NHS Trusts to reduce their plastic footprint.

Design And Methods: In this study, we conducted an in-depth case study in the Royal Cornwall Hospitals NHS Trust to investigate plastic-related issues in a typical NHS Trust before, during and after the pandemic. We first collected hospital routine data on both procurement and usage of single-use PPE (including face masks, aprons, and gowns) for the time period between April 2019 and August 2020. We then interviewed 12 hospital staff across a wide remit, from senior managers to consultants, nurses and catering staff, to gather qualitative evidence on the overall impact of COVID-19 on the Trust regarding plastic use.

Results: We found that although COVID-19 had increased the procurement and the use of single-use plastic substantially during the pandemic, it did not appear to have changed the focus of the hospital on implementing measures to reduce single-use plastic in the long term. We then discussed the barriers and opportunities to tackle plastic issues within the NHS in the post-COVID world, for example, a circular healthcare model.

Conclusion: investment is needed in technologies and processes that can recycle and reuse a wider range of single-use plastics, and innovate sustainable alternatives to replace single-use consumables used in the NHS to construct a fully operational closed material loop healthcare system.
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http://dx.doi.org/10.4081/jphr.2021.2483DOI Listing
August 2021

Associations between green/blue spaces and mental health across 18 countries.

Sci Rep 2021 04 26;11(1):8903. Epub 2021 Apr 26.

European Centre for Environment and Human Health, University of Exeter Medical School, Exeter, UK.

Living near, recreating in, and feeling psychologically connected to, the natural world are all associated with better mental health, but many exposure-related questions remain. Using data from an 18-country survey (n = 16,307) we explored associations between multiple measures of mental health (positive well-being, mental distress, depression/anxiety medication use) and: (a) exposures (residential/recreational visits) to different natural settings (green/inland-blue/coastal-blue spaces); and (b) nature connectedness, across season and country. People who lived in greener/coastal neighbourhoods reported higher positive well-being, but this association largely disappeared when recreational visits were controlled for. Frequency of recreational visits to green, inland-blue, and coastal-blue spaces in the last 4 weeks were all positively associated with positive well-being and negatively associated with mental distress. Associations with green space visits were relatively consistent across seasons and countries but associations with blue space visits showed greater heterogeneity. Nature connectedness was also positively associated with positive well-being and negatively associated with mental distress and was, along with green space visits, associated with a lower likelihood of using medication for depression. By contrast inland-blue space visits were associated with a greater likelihood of using anxiety medication. Results highlight the benefits of multi-exposure, multi-response, multi-country studies in exploring complexity in nature-health associations.
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http://dx.doi.org/10.1038/s41598-021-87675-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8076244PMC
April 2021

The Ocean Decade-Opportunities for Oceans and Human Health Programs to Contribute to Public Health.

Am J Public Health 2021 05;111(5):808-811

Lora E. Fleming, Michael Depledge, Claire Eatock, Ruth Garside, Bruce Maycock, Bethany R. Roberts, and Mathew P. White are with the European Centre for Environment and Human Health, University of Exeter Medical School, Truro, Cornwall, UK. Timothy Bouley is with the BioFeyn SAS, Paris, France. Easkey Britton is with the Whitaker Institute, National University of Ireland, Galway, Ireland. Sam Dupont is with the Department for Biological and Environmental Sciences, University of Gothenburg, Fiskebäckskil, Sweden. Johanna J. Heymans and Paula Kellett are with the European Marine Board, Ostend, Belgium. Josep Lloret is with the University of Girona, Oceans and Human Health Chair, Girona, Catalonia, Spain. Sabine Pahl is with the Cognitive Science HUB, Department of Psychology, University of Vienna, Vienna, Austria. Catharina J. M. Philippart is with the Royal Netherlands Institute for Sea Research, Texel, Netherlands. Torsten Thiele is with the Institute for Advanced Sustainability Studies, Potsdam, Germany. Susanne Wuijts is with the National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands.

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http://dx.doi.org/10.2105/AJPH.2021.306229DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8034031PMC
May 2021

The value of blue-space recreation and perceived water quality across Europe: A contingent behaviour study.

Sci Total Environ 2021 Jun 1;771:145597. Epub 2021 Mar 1.

European Centre for Environment and Human Health, University of Exeter Medical School, United Kingdom. Electronic address:

This study estimates the value of recreational visits to blue-space sites across 14 EU Member States, representing 78% of the Union's population. Across all countries surveyed, respondents made an average of 47 blue-space visits per person per year. Employing travel cost and contingent behaviour methods, the value of a visit is estimated at €41.32 which adds up to a recreational value of €631bn per year for the total adult population surveyed. Using the Bathing Water Directive's water quality designation, the analysis shows that a one-level improvement in water quality leads to 3.13 more visits (+6.67%), whereas a one-level deterioration leads to 9.77 fewer annual visits (-20.83%). This study provides valuations of benefits of recreation and changes of recreational values due to changes in surface water quality, which can be compared to the implementation and monitoring costs of efforts under the EU's Bathing Water, Water Framework and Marine Strategy Framework Directives.
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http://dx.doi.org/10.1016/j.scitotenv.2021.145597DOI Listing
June 2021

A Transdisciplinary Approach to Recovering Natural and Cultural Landscape and Place Identification: A Case Study of Can Moritz Spring (Rubí, Spain).

Int J Environ Res Public Health 2021 02 10;18(4). Epub 2021 Feb 10.

ISGlobal, 08193 Barcelona, Spain.

The perception of the quality of green and blue spaces can be key in the relationship between a community and its local landscape (i.e., place identification). The lack of transdisciplinary training and social-specific education of landscape architects regarding the complexity of landscape as a participative cultural artefact limits reaching the general population. Bridging this gap of landscape and place identification and evaluation by a local community was the main objective of the present case study conducted at an abandoned spring and seasonal stream area in Rubí (Spain). The "Steinitz method" of landscape evaluation was used as a participatory method to activate community members to learn about and express their visual preferences regarding this neglected landscape. Bottom-up interventions applying an "urban acupuncture" approach in the area identified as the least attractive by the residents were co-designed and combined with a top-down restoration of a nearby, existing but derelict and hidden, spring. In addition, before and after planning and implementing the intervention, we conducted surveys about the community perception, sense of belonging and use of the space. We observed that the lack of awareness of the inhabitants about this spring was an obstacle preventing the community from embracing the potential for health and wellbeing presented by the spring and adjacent landscape. Following the work, the landscape saw increasing use, and the historic spring was brought back to life as a resource to help people to improve their health and wellbeing.
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http://dx.doi.org/10.3390/ijerph18041709DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7916719PMC
February 2021

Redesigning walking brochures using behaviour change theory: implications for walking intentions in natural environments.

Health Promot Int 2021 Aug;36(4):1126-1139

Faculty of Medicine & Dentistry, University of Plymouth, N6, ITTC, Tamar Science Park, Plymouth, Devon PL6 8BX, UK.

Natural environments can be used to promote health through facilitating recreational walking. However, efforts to encourage this often neglect messages identified in psychological research that are effective at influencing intentions to walk. This is despite the National Institute for Health and Care Excellence stating that promotional efforts should utilize theoretical frameworks of behaviour change and be targeted towards less active adults. As an illustrative example, this experiment compared a prototypical recreational walking brochure with an "enhanced" version including such persuasive messages on people's intentions to walk for recreation in natural environments. The enhanced brochure heightened intentions for inexperienced recreational walkers through our hypothesized mechanisms, but appeared to dissuade already-experienced walkers. Optimal messaging strategies in recreational walking brochures require tailoring to more and less active readerships. Guidelines are provided for authors of recreational walking brochures, though the principles and techniques could easily be extended to other means of outdoor walking promotion.
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http://dx.doi.org/10.1093/heapro/daaa150DOI Listing
August 2021

Human Health and Ocean Pollution.

Ann Glob Health 2020 12 3;86(1):151. Epub 2020 Dec 3.

Nigerian Institute for Medical Research, Lagos, NG.

Background: Pollution - unwanted waste released to air, water, and land by human activity - is the largest environmental cause of disease in the world today. It is responsible for an estimated nine million premature deaths per year, enormous economic losses, erosion of human capital, and degradation of ecosystems. Ocean pollution is an important, but insufficiently recognized and inadequately controlled component of global pollution. It poses serious threats to human health and well-being. The nature and magnitude of these impacts are only beginning to be understood.

Goals: (1) Broadly examine the known and potential impacts of ocean pollution on human health. (2) Inform policy makers, government leaders, international organizations, civil society, and the global public of these threats. (3) Propose priorities for interventions to control and prevent pollution of the seas and safeguard human health.

Methods: Topic-focused reviews that examine the effects of ocean pollution on human health, identify gaps in knowledge, project future trends, and offer evidence-based guidance for effective intervention.

Environmental Findings: Pollution of the oceans is widespread, worsening, and in most countries poorly controlled. It is a complex mixture of toxic metals, plastics, manufactured chemicals, petroleum, urban and industrial wastes, pesticides, fertilizers, pharmaceutical chemicals, agricultural runoff, and sewage. More than 80% arises from land-based sources. It reaches the oceans through rivers, runoff, atmospheric deposition and direct discharges. It is often heaviest near the coasts and most highly concentrated along the coasts of low- and middle-income countries. Plastic is a rapidly increasing and highly visible component of ocean pollution, and an estimated 10 million metric tons of plastic waste enter the seas each year. Mercury is the metal pollutant of greatest concern in the oceans; it is released from two main sources - coal combustion and small-scale gold mining. Global spread of industrialized agriculture with increasing use of chemical fertilizer leads to extension of Harmful Algal Blooms (HABs) to previously unaffected regions. Chemical pollutants are ubiquitous and contaminate seas and marine organisms from the high Arctic to the abyssal depths.

Ecosystem Findings: Ocean pollution has multiple negative impacts on marine ecosystems, and these impacts are exacerbated by global climate change. Petroleum-based pollutants reduce photosynthesis in marine microorganisms that generate oxygen. Increasing absorption of carbon dioxide into the seas causes ocean acidification, which destroys coral reefs, impairs shellfish development, dissolves calcium-containing microorganisms at the base of the marine food web, and increases the toxicity of some pollutants. Plastic pollution threatens marine mammals, fish, and seabirds and accumulates in large mid-ocean gyres. It breaks down into microplastic and nanoplastic particles containing multiple manufactured chemicals that can enter the tissues of marine organisms, including species consumed by humans. Industrial releases, runoff, and sewage increase frequency and severity of HABs, bacterial pollution, and anti-microbial resistance. Pollution and sea surface warming are triggering poleward migration of dangerous pathogens such as the species. Industrial discharges, pharmaceutical wastes, pesticides, and sewage contribute to global declines in fish stocks.

Human Health Findings: Methylmercury and PCBs are the ocean pollutants whose human health effects are best understood. Exposures of infants to these pollutants through maternal consumption of contaminated seafood can damage developing brains, reduce IQ and increase children's risks for autism, ADHD and learning disorders. Adult exposures to methylmercury increase risks for cardiovascular disease and dementia. Manufactured chemicals - phthalates, bisphenol A, flame retardants, and perfluorinated chemicals, many of them released into the seas from plastic waste - can disrupt endocrine signaling, reduce male fertility, damage the nervous system, and increase risk of cancer. HABs produce potent toxins that accumulate in fish and shellfish. When ingested, these toxins can cause severe neurological impairment and rapid death. HAB toxins can also become airborne and cause respiratory disease. Pathogenic marine bacteria cause gastrointestinal diseases and deep wound infections. With climate change and increasing pollution, risk is high that infections, including cholera, will increase in frequency and extend to new areas. All of the health impacts of ocean pollution fall disproportionately on vulnerable populations in the Global South - environmental injustice on a planetary scale.

Conclusions: Ocean pollution is a global problem. It arises from multiple sources and crosses national boundaries. It is the consequence of reckless, shortsighted, and unsustainable exploitation of the earth's resources. It endangers marine ecosystems. It impedes the production of atmospheric oxygen. Its threats to human health are great and growing, but still incompletely understood. Its economic costs are only beginning to be counted.Ocean pollution can be prevented. Like all forms of pollution, ocean pollution can be controlled by deploying data-driven strategies based on law, policy, technology, and enforcement that target priority pollution sources. Many countries have used these tools to control air and water pollution and are now applying them to ocean pollution. Successes achieved to date demonstrate that broader control is feasible. Heavily polluted harbors have been cleaned, estuaries rejuvenated, and coral reefs restored.Prevention of ocean pollution creates many benefits. It boosts economies, increases tourism, helps restore fisheries, and improves human health and well-being. It advances the Sustainable Development Goals (SDG). These benefits will last for centuries.

Recommendations: World leaders who recognize the gravity of ocean pollution, acknowledge its growing dangers, engage civil society and the global public, and take bold, evidence-based action to stop pollution at source will be critical to preventing ocean pollution and safeguarding human health.Prevention of pollution from land-based sources is key. Eliminating coal combustion and banning all uses of mercury will reduce mercury pollution. Bans on single-use plastic and better management of plastic waste reduce plastic pollution. Bans on persistent organic pollutants (POPs) have reduced pollution by PCBs and DDT. Control of industrial discharges, treatment of sewage, and reduced applications of fertilizers have mitigated coastal pollution and are reducing frequency of HABs. National, regional and international marine pollution control programs that are adequately funded and backed by strong enforcement have been shown to be effective. Robust monitoring is essential to track progress.Further interventions that hold great promise include wide-scale transition to renewable fuels; transition to a circular economy that creates little waste and focuses on equity rather than on endless growth; embracing the principles of green chemistry; and building scientific capacity in all countries.Designation of Marine Protected Areas (MPAs) will safeguard critical ecosystems, protect vulnerable fish stocks, and enhance human health and well-being. Creation of MPAs is an important manifestation of national and international commitment to protecting the health of the seas.
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http://dx.doi.org/10.5334/aogh.2831DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7731724PMC
December 2020

Contact with blue-green spaces during the COVID-19 pandemic lockdown beneficial for mental health.

Sci Total Environ 2021 Feb 26;756:143984. Epub 2020 Nov 26.

AZTI, Marine Research, Basque Research and Technology Alliance (BRTA), Herrera Kaia, Portualdea z/g, 20110 Pasaia, Gipuzkoa, Spain.

There is growing evidence that ecosystem services and especially the exposure to the natural world (blue-green spaces) have potential benefits for mental health and well-being. The COVID-19 pandemic and the measures adopted to control it provide a natural experiment to investigate the links between nature exposure and mental health under extreme conditions. Using a survey distributed online, we tested the following hypotheses: 1) People will show greater symptoms of depression and anxiety under lockdown conditions that did not allow contact with outdoor nature spaces; 2) Where access to public outdoor nature spaces was strictly restricted, (2a) those with green/blue nature view or (2b) access to private outdoor spaces such as a garden or balcony will show fewer symptoms of depression and anxiety, and a more positive mood. Based on 5218 responses from 9 countries, we found that lockdown severity significantly affected mental health, while contact with nature helped people to cope with these impacts, especially for those under strict lockdown. People under strict lockdown in Spain (3403 responses), perceived that nature helped them to cope with lockdown measures; and emotions were more positive among individuals with accessible outdoor spaces and blue-green elements in their views. These findings can help decision-makers in developing potential future lockdown measures to mitigate the negative impacts, helping people to be more resilient and maintain better mental health, using the benefits that ecosystem services are providing us.
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http://dx.doi.org/10.1016/j.scitotenv.2020.143984DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7688424PMC
February 2021

Results from an 18 country cross-sectional study examining experiences of nature for people with common mental health disorders.

Sci Rep 2020 11 6;10(1):19408. Epub 2020 Nov 6.

European Centre for Environment and Human Health, University of Exeter Medical School, c/o Knowledge Spa, Royal Cornwall Hospital, Truro, TR1 3HD, Cornwall, UK.

Exposure to natural environments is associated with a lower risk of common mental health disorders (CMDs), such as depression and anxiety, but we know little about nature-related motivations, practices and experiences of those already experiencing CMDs. We used data from an 18-country survey to explore these issues (n = 18,838), taking self-reported doctor-prescribed medication for depression and/or anxiety as an indicator of a CMD (n = 2698, 14%). Intrinsic motivation for visiting nature was high for all, though slightly lower for those with CMDs. Most individuals with a CMD reported visiting nature ≥ once a week. Although perceived social pressure to visit nature was associated with higher visit likelihood, it was also associated with lower intrinsic motivation, lower visit happiness and higher visit anxiety. Individuals with CMDs seem to be using nature for self-management, but 'green prescription' programmes need to be sensitive, and avoid undermining intrinsic motivation and nature-based experiences.
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http://dx.doi.org/10.1038/s41598-020-75825-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7648621PMC
November 2020

Marine harmful algal blooms and human health: A systematic scoping review.

Harmful Algae 2020 09 17;98:101901. Epub 2020 Sep 17.

European Centre for Environment and Human Health, Truro, UK; University of Exeter Medical School, Exeter, UK. Electronic address:

Exposure to harmful algal blooms (HABs) can lead to well recognised acute patterns of illness in humans. The objective of this scoping review was to use an established methodology and the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting framework to map the evidence for associations between marine HABs and observed both acute and chronic human health effects. A systematic and reproducible search of publications from 1985 until May 2019 was conducted using diverse electronic databases. Following de-duplication, 5301 records were identified, of which 380 were included in the final qualitative synthesis. The majority of studies (220; 57.9%) related to Ciguatera Poisoning. Anecdotal and case reports made up the vast majority of study types (242; 63.7%), whereas there were fewer formal epidemiological studies (35; 9.2%). Only four studies related to chronic exposure to HABs. A low proportion of studies reported the use of human specimens for confirmation of the cause of illness (32; 8.4%). This study highlighted gaps in the evidence base including a lack of formal surveillance and epidemiological studies, limited use of toxin measurements in human samples, and a scarcity of studies of chronic exposure. Future research and policy should provide a baseline understanding of the burden of human disease to inform the evaluation of the current and future impacts of climate change and HABs on human health.
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http://dx.doi.org/10.1016/j.hal.2020.101901DOI Listing
September 2020

Blue space, health and well-being: A narrative overview and synthesis of potential benefits.

Environ Res 2020 12 22;191:110169. Epub 2020 Sep 22.

European Centre for Environment & Human Health, University of Exeter, UK.

Research into the potential health and well-being benefits from exposure to green spaces such as parks and woodlands has led to the development of several frameworks linking the different strands of evidence. The current paper builds on these to provide a model of how exposure to aquatic environments, or blue spaces such as rivers, lakes and the coast, in particular, may benefit health and well-being. Although green and blue spaces share many commonalities, there are also important differences. Given the breadth of the research, spanning multiple disciplines and research methodologies, a narrative review approach was adopted which aimed to highlight key issues and processes rather than provide a definitive balance of evidence summary. Novel aspects of our framework included the inclusion of outcomes that are only indirectly good for health through being good for the environment, the addition of nature connectedness as both a trait and state, and feedback loops where actions/interventions to increase exposure are implemented. Limitations of the review and areas for future work, including the need to integrate potential benefits with potential risks, are discussed.
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http://dx.doi.org/10.1016/j.envres.2020.110169DOI Listing
December 2020

Health status, healthcare utilisation, and quality of life among the coastal communities in Sabah: Protocol of a population-based survey.

Medicine (Baltimore) 2020 Sep;99(37):e22067

Department of Urban and Regional Planning, Faculty of Built Environment, University of Malaya.

Introduction: Coastal areas in Malaysia can have important impacts on the livelihoods and health of local communities. Efforts by Malaysian government to develop and improve the landscape and ecosystem have been planned; however, the progress has been relatively slow because some of the coastal areas are remote and relatively inaccessible. Thus, these coastal communities face various challenges in health, healthcare and quality of life. This paper presents a study protocol to examine the health status, healthcare utilisation, and quality of life among the coastal communities. In addition, the relationship between the community and their coastal environment is examined.

Methodology And Analysis: The population of interest is the coastal communities residing within the Tun Mustapha Park in Sabah, Malaysia. The data collection is planned for a duration of 6 months and the findings are expected by December 2020. A random cluster sampling will be conducted at three districts of Sabah. This study will collect 600 adult respondents (300 households are estimated to be collected) at age of 18 and above. The project is a cross sectional study via face-to-face interview with administered questionnaires, anthropometrics measurements and observation of the living condition performed by trained interviewers.
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http://dx.doi.org/10.1097/MD.0000000000022067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489655PMC
September 2020

Urban nature and physical activity: Investigating associations using self-reported and accelerometer data and the role of household income.

Environ Res 2020 11 22;190:109899. Epub 2020 Jul 22.

European Centre for Environment and Human Health, University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall, TR1 3HD, UK.

Background: Physical inactivity is a major public health concern. Natural, or semi-natural, environments may encourage physical activity, but the influences of socio-economic factors have been under-researched.

Methods: We explored the associations between meeting physical activity (PA) guidelines and both neighbourhood green (area coverage) and blue (freshwater coverage and coastal proximity) environments for urban adults using data from the Health Survey for England [HSE] (2008/2012). We considered different domains of self-reported PA: walking (n = 18,391), sports and other exercise (n = 18,438), non-recreational (domestic/gardening/occupational; n = 18,446) and all three domains combined (n = 18,447); as well as accelerometer-derived PA data using a subsample (n = 1,774). Relationships were stratified by equivalised household income as an indicator of socio-economic status.

Results: After adjusting for covariates, living <5 km from the coast was associated with significantly higher odds of meeting UK 2010 guidelines through self-reported total, walking and non-recreational PA (e.g. total PA, <5 km vs. >20 km, adjusted odds ratio (OR) = 1.26; 95% confidence interval (CI) = 1.15-1.39) but unrelated to sports and exercise. Greater neighbourhood greenspace, however, was only associated with significantly higher odds of meeting guidelines through non-recreational PA alone (e.g. 80-100% vs. <20% OR = 1.32; 95% CI = 1.12-1.56). Although associations were most consistent in the lowest income quintile, income-related results were mixed. Relationships were not replicated in the smaller accelerometry subsample.

Conclusion: Our self-report findings for the differing domains of PA as a function of neighbourhood green and blue space broadly replicated previous research, yet the reasons for the observed differences between PA domains and environments remain unclear. We did not observe any associations between environmental variables and accelerometer-measured PA; further research with larger samples is needed.
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http://dx.doi.org/10.1016/j.envres.2020.109899DOI Listing
November 2020

The Roses Ocean and Human Health Chair: A New Way to Engage the Public in Oceans and Human Health Challenges.

Int J Environ Res Public Health 2020 07 14;17(14). Epub 2020 Jul 14.

European Centre for Environment and Human Health, University of Exeter Medical School, Cornwall TR1 3HD, UK.

Involving and engaging stakeholders is crucial for studying and managing the complex interactions between marine ecosystems and human health and wellbeing. The Oceans and Human Health Chair was founded in the town of Roses (Catalonia, Spain, NW Mediterranean) in 2018, the fruit of a regional partnership between various stakeholders, and for the purpose of leading the way to better health and wellbeing through ocean research and conservation. The Chair is located in an area of the Mediterranean with a notable fishing, tourist, and seafaring tradition and is close to a marine reserve, providing the opportunity to observe diverse environmental conditions and coastal and maritime activities. The Chair is a case study demonstrating that local, collaborative, transdisciplinary, trans-sector, and bottom-up approaches offer tremendous opportunities for engaging coastal communities to help support long-lasting solutions that benefit everyone, and especially those living by the sea or making their living from the goods and services provided by the sea. Furthermore, the Chair has successfully integrated most of its experts in oceans and human health from the most prestigious institutions in Catalonia. The Chair focuses on three main topics identified by local stakeholders: Fish and Health; Leisure, Health, and Wellbeing; and Medicines from the Sea. Led by stakeholder engagement, the Chair can serve as a novel approach within the oceans and human health field of study to tackle a variety of environmental and public health challenges related to both communicable and non-communicable diseases, within the context of sociocultural issues. Drawing on the example provided by the Chair, four principles are established to encourage improved participatory processes in the oceans and human health field: bottom-up, "think local", transdisciplinary and trans-sectorial, and "balance the many voices".
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http://dx.doi.org/10.3390/ijerph17145078DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7400534PMC
July 2020

Ocean Acidification and Human Health.

Int J Environ Res Public Health 2020 06 24;17(12). Epub 2020 Jun 24.

Department for Biological and Environmental Sciences, University of Gothenburg, Kristineberg 566, 45178 Fiskebäckskil, Sweden.

The ocean provides resources key to human health and well-being, including food, oxygen, livelihoods, blue spaces, and medicines. The global threat to these resources posed by accelerating ocean acidification is becoming increasingly evident as the world's oceans absorb carbon dioxide emissions. While ocean acidification was initially perceived as a threat only to the marine realm, here we argue that it is also an emerging human health issue. Specifically, we explore how ocean acidification affects the quantity and quality of resources key to human health and well-being in the context of: (1) malnutrition and poisoning, (2) respiratory issues, (3) mental health impacts, and (4) development of medical resources. We explore mitigation and adaptation management strategies that can be implemented to strengthen the capacity of acidifying oceans to continue providing human health benefits. Importantly, we emphasize that the cost of such actions will be dependent upon the socioeconomic context; specifically, costs will likely be greater for socioeconomically disadvantaged populations, exacerbating the current inequitable distribution of environmental and human health challenges. Given the scale of ocean acidification impacts on human health and well-being, recognizing and researching these complexities may allow the adaptation of management such that not only are the harms to human health reduced but the benefits enhanced.
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http://dx.doi.org/10.3390/ijerph17124563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7344635PMC
June 2020

Correction to: Phthalates and asthma in children and adults: US NHANES 2007-2012.

Environ Sci Pollut Res Int 2020 04;27(10):11459

European Centre for Environment and Human Health, Knowledge Spa, Royal Cornwall Hospital, University of Exeter Medical School, Truro, Cornwall, TR1 3HD, UK.

The correct presentation name of the 4th Author is shown in this paper.
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http://dx.doi.org/10.1007/s11356-020-07869-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7645458PMC
April 2020

Associations between pro-environmental behaviour and neighbourhood nature, nature visit frequency and nature appreciation: Evidence from a nationally representative survey in England.

Environ Int 2020 03 9;136:105441. Epub 2020 Jan 9.

European Centre for Environment and Human Health, University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall TR1 3HD, UK. Electronic address:

Progress on changing human behaviour to meet the challenges of regional and global sustainability has been slow. Building on theory as well as small-scale survey and experimental evidence that exposure to nature may be associated with greater pro-environmentalism, the aim of the current study was to quantify relationships between exposure to nature (operationalised as neighbourhood greenspace, coastal proximity, and recreational nature visits) as well as appreciation of the natural world, and self-reported pro-environmental behaviour for the adult population of England. Using data from a nationally representative sample (N = 24,204), and controlling for potential confounders, a structural equation model was used to estimate relationships. Indirect effects of neighbourhood exposures via nature visits and nature appreciation were accounted for. We found positive relationships between both recreational nature visits and nature appreciation and pro-environmental behaviour across both the whole sample and key socio-demographic groups. The more individuals visited nature for recreation and the more they appreciated the natural world, the more pro-environmental behaviour they reported. Although rural and coastal dwellers tended to also be more pro-environmental on average, patterns were complex, potentially reflecting situational constraints and opportunities. Importantly, positive associations between pro-environmental behaviours and high neighbourhood greenspace and coastal proximity were present for both high and low socio-economic status households. Improving access to, and contact with, nature, e.g., through better urban planning, may be one approach for meeting sustainability targets.
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http://dx.doi.org/10.1016/j.envint.2019.105441DOI Listing
March 2020

Coastal proximity and mental health among urban adults in England: The moderating effect of household income.

Health Place 2019 09 1;59:102200. Epub 2019 Oct 1.

European Centre for Environment and Human Health, European Centre for Environment and Human Health, University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital Treliske, Truro, Cornwall, TR1 3HD, UK.

After adjusting for covariates, self-reported general health in England is higher among populations living closer to the coast, and the association is strongest amongst more deprived groups. We explored whether similar findings were present for mental health using cross-sectional data for urban adults in the Health Survey for England (2008-2012, N ≥25,963). For urban adults, living ≤1 km from the coast, in comparison to >50 km, was associated with better mental health as measured by the GHQ12. Stratification by household income revealed this was only amongst the lowest-earning households, and extended to ≤5 km. Our findings support the contention that, for urban adults, coastal settings may help to reduce health inequalities in England.
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http://dx.doi.org/10.1016/j.healthplace.2019.102200DOI Listing
September 2019

Phthalates and asthma in children and adults: US NHANES 2007-2012.

Environ Sci Pollut Res Int 2019 Sep 31;26(27):28256-28269. Epub 2019 Jul 31.

European Centre for Environment and Human Health, Knowledge Spa, Royal Cornwall Hospital, University of Exeter Medical School, Truro, Cornwall, TR1 3HD, UK.

Environmental exposure to phthalates may contribute to an increased risk of asthma in children and adults. We aimed to assess the direction and strength of the association between urinary phthalates metabolites and current asthma in children and adults that participated in the National Health and Nutrition Examination Survey (NHANES) 2007-2012. Data on ten urinary phthalate metabolites, self-reported questionnaires, spirometry measures, and covariates were obtained from 7765 participants (28.1% were children aged 6-17 years) taking part in the NHANES 2007-2012. Asthma was assessed using self-reported questionnaires for children and adults, and via spirometry measures for adults alone. We used crude and adjusted logistic regression models to estimate the odds ratios (ORs) and 95% confidence interval (CI) per one log unit change in the concentration of phthalate metabolites. We further modeled the effect modification by sex. Out of 10 metabolites, only mono-benzyl phthalate (MBzP) was positively associated with the prevalence of self-reported asthma in children, after adjusting for a range of potential confounders (odds ratio 1.54; 95% confidence interval 1.05-2.27). No significant relationship was observed for adults. The association of mono-ethyl phthalate (MEP) was modified by sex, with significantly increased odds of asthma among males [boys (2.00; 1.14-3.51); adult males (1.32; 1.04-1.69)]. While no other phthalates showed a positive relationship with current asthma in males, mono-(carboxynonyl) phthalate (MCNP) and mono-(3-carboxylpropyl) phthalate (MCPP) were inversely associated with spirometrically defined asthma in adult females. A sex-specific relationship in adults was evident when spirometry, but not self-reported measures were used to define asthma. We found no clear association between exposure to phthalates and current asthma, except for a significant relationship between MBzP metabolites and self-reported asthma in children. As a result, exposure to phthalates and asthma development and/or exacerbations remains controversial, suggesting a need for a well-designed longitudinal study.
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http://dx.doi.org/10.1007/s11356-019-06003-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6791917PMC
September 2019

Time and tide.

BMJ 2019 07 17;366:l4671. Epub 2019 Jul 17.

European Centre for Environment and Human Health, University of Exeter Medical School, Truro, Cornwall, UK.

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http://dx.doi.org/10.1136/bmj.l4671DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6635814PMC
July 2019

Spending at least 120 minutes a week in nature is associated with good health and wellbeing.

Sci Rep 2019 06 13;9(1):7730. Epub 2019 Jun 13.

European Centre for Environment and Human Health, University of Exeter Medical School, Exeter, UK.

Spending time in natural environments can benefit health and well-being, but exposure-response relationships are under-researched. We examined associations between recreational nature contact in the last seven days and self-reported health and well-being. Participants (n = 19,806) were drawn from the Monitor of Engagement with the Natural Environment Survey (2014/15-2015/16); weighted to be nationally representative. Weekly contact was categorised using 60 min blocks. Analyses controlled for residential greenspace and other neighbourhood and individual factors. Compared to no nature contact last week, the likelihood of reporting good health or high well-being became significantly greater with contact ≥120 mins (e.g. 120-179 mins: ORs [95%CIs]: Health = 1.59 [1.31-1.92]; Well-being = 1.23 [1.08-1.40]). Positive associations peaked between 200-300 mins per week with no further gain. The pattern was consistent across key groups including older adults and those with long-term health issues. It did not matter how 120 mins of contact a week was achieved (e.g. one long vs. several shorter visits/week). Prospective longitudinal and intervention studies are a critical next step in developing possible weekly nature exposure guidelines comparable to those for physical activity.
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http://dx.doi.org/10.1038/s41598-019-44097-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6565732PMC
June 2019

Neurological illnesses associated with Florida red tide (Karenia brevis) blooms.

Harmful Algae 2019 02 1;82:73-81. Epub 2019 Mar 1.

Marine Policy Center, Woods Hole Oceanographic Institution, Woods Hole, MA, USA.

Human respiratory and gastrointestinal illnesses can result from exposures to brevetoxins originating from coastal Florida red tide blooms, comprising the marine alga Karenia brevis (K. brevis). Only limited research on the extent of human health risks and illness costs due to K. brevis blooms has been undertaken to date. Because brevetoxins are known neurotoxins that are able to cross the blood-brain barrier, it is possible that exposure to brevetoxins may be associated with neurological illnesses. This study explored whether K. brevis blooms may be associated with increases in the numbers of emergency department visits for neurological illness. An exposure-response framework was applied to test the effects of K. brevis blooms on human health, using secondary data from diverse sources. After controlling for resident population, seasonal and annual effects, significant increases in emergency department visits were found specifically for headache (ICD-9 784.0) as a primary diagnosis during proximate coastal K. brevis blooms. In particular, an increased risk for older residents (≥55 years) was identified in the coastal communities of six southwest Florida counties during K. brevis bloom events. The incidence of headache associated with K. brevis blooms showed a small but increasing association with K. brevis cell densities. Rough estimates of the costs of this illness were developed for hypothetical bloom occurrences.
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http://dx.doi.org/10.1016/j.hal.2018.07.002DOI Listing
February 2019

Seasonality and the effects of weather on Campylobacter infections.

BMC Infect Dis 2019 Mar 13;19(1):255. Epub 2019 Mar 13.

Statistics, Modelling and Economics Department, National Infection Service, Public Health England, 61, Colindale Avenue, London, NW9 5EQ, UK.

Background: Campylobacteriosis is a major public health concern. The weather factors that influence spatial and seasonal distributions are not fully understood.

Methods: To investigate the impacts of temperature and rainfall on Campylobacter infections in England and Wales, cases of Campylobacter were linked to local temperature and rainfall at laboratory postcodes in the 30 days before the specimen date. Methods for investigation included a comparative conditional incidence, wavelet, clustering, and time series analyses.

Results: The increase of Campylobacter infections in the late spring was significantly linked to temperature two weeks before, with an increase in conditional incidence of 0.175 cases per 100,000 per week for weeks 17 to 24; the relationship to temperature was not linear. Generalized structural time series model revealed that changes in temperature accounted for 33.3% of the expected cases of Campylobacteriosis, with an indication of the direction and relevant temperature range. Wavelet analysis showed a strong annual cycle with additional harmonics at four and six months. Cluster analysis showed three clusters of seasonality with geographic similarities representing metropolitan, rural, and other areas.

Conclusions: The association of Campylobacteriosis with temperature is likely to be indirect. High-resolution spatial temporal linkage of weather parameters and cases is important in improving weather associations with infectious diseases. The primary driver of Campylobacter incidence remains to be determined; other avenues, such as insect contamination of chicken flocks through poor biosecurity should be explored.
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http://dx.doi.org/10.1186/s12879-019-3840-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6417031PMC
March 2019

Public involvement in research about environmental change and health: A case study.

Health (London) 2019 03;23(2):215-233

University of Exeter, UK.

Involving and engaging the public are crucial for effective prioritisation, dissemination and implementation of research about the complex interactions between environments and health. Involvement is also important to funders and policy makers who often see it as vital for building trust and justifying the investment of public money. In public health research, 'the public' can seem an amorphous target for researchers to engage with, and the short-term nature of research projects can be a challenge. Technocratic and pedagogical approaches have frequently met with resistance, so public involvement needs to be seen in the context of a history which includes contested truths, power inequalities and political activism. It is therefore vital for researchers and policy makers, as well as public contributors, to share best practice and to explore the challenges encountered in public involvement and engagement. This article presents a theoretically informed case study of the contributions made by the Health and Environment Public Engagement Group to the work of the National Institute for Health Research (NIHR) Health Protection Research Unit in Environmental Change and Health (HPRU-ECH). We describe how Health and Environment Public Engagement Group has provided researchers in the HPRU-ECH with a vehicle to support access to public views on multiple aspects of the research work across three workshops, discussion of ongoing research issues at meetings and supporting dissemination to local government partners, as well as public representation on the HPRU-ECH Advisory Board. We conclude that institutional support for standing public involvement groups can provide conduits for connecting public with policy makers and academic institutions. This can enable public involvement and engagement, which would be difficult, if not impossible, to achieve in individual short-term and unconnected research projects.
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http://dx.doi.org/10.1177/1363459318809405DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6388412PMC
March 2019

Health Benefits of Physical Activity Related to an Urban Riverside Regeneration.

Int J Environ Res Public Health 2019 02 5;16(3). Epub 2019 Feb 5.

ISGlobal (Global Health Institute Barcelona), 08003 Barcelona, Spain.

The promotion of physical activity through better urban design is one pathway by which health and well-being improvements can be achieved. This study aimed to quantify health and health-related economic impacts associated with physical activity in an urban riverside park regeneration project in Barcelona, Spain. We used data from Barcelona local authorities and meta-analysis assessing physical activity and health outcomes to develop and apply the "Blue Active Tool". We estimated park user health impacts in terms of all-cause mortality, morbidity (ischemic heart disease; ischemic stroke; type 2 diabetes; cancers of the colon and breast; and dementia), disability-adjusted life years (DALYs) and health-related economic impacts. We estimated that 5753 adult users visited the riverside park daily and performed different types of physical activity (walking for leisure or to/from work, cycling, and running). Related to the physical activity conducted on the riverside park, we estimated an annual reduction of 7.3 deaths (95% CI: 5.4; 10.2), and 6.2 cases of diseases (95% CI: 2.0; 11.6). This corresponds to 11.9 DALYs (95% CI: 3.4; 20.5) and an annual health-economic impact of 23.4 million euros (95% CI: 17.2 million; 32.8 million). The urban regeneration intervention of this riverside park provides health and health-related economic benefits to the population using the infrastructure.
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http://dx.doi.org/10.3390/ijerph16030462DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6388232PMC
February 2019

Making the Case for "Whole System" Approaches: Integrating Public Health and Housing.

Int J Environ Res Public Health 2018 10 24;15(11). Epub 2018 Oct 24.

Public Health, Cornwall Council, Truro TR1 3AY, UK.

Housing conditions have been an enduring focus for public health activity throughout the modern public health era. However, the nature of the housing and health challenge has changed in response to an evolution in the understanding of the diverse factors influencing public health. Today, the traditional public health emphasis on the type and quality of housing merges with other wider determinants of health. These include the neighbourhood, community, and "place" where a house is located, but also the policies which make access to a healthy house possible and affordable for everyone. Encouragingly, these approaches to policy and action on housing have the potential to contribute to the "triple win" of health and well-being, equity, and environmental sustainability. However, more effective housing policies (and in public health in general) that adopt more systemic approaches to addressing the complex interactions between health, housing, and wider environment are needed. This paper illustrates some of the key components of the housing and health challenge in developed countries, and presents a conceptual model to co-ordinate activities that can deliver the "triple win." This is achieved by offering a perspective on how to navigate more effectively, inclusively and across sectors when identifying sustainable housing interventions.
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http://dx.doi.org/10.3390/ijerph15112345DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6267345PMC
October 2018

Pathogen seasonality and links with weather in England and Wales: a big data time series analysis.

BMC Public Health 2018 Aug 28;18(1):1067. Epub 2018 Aug 28.

European Centre for Environment and Human Health, University of Exeter Medical School, Truro, England.

Background: Many infectious diseases of public health importance display annual seasonal patterns in their incidence. We aimed to systematically document the seasonality of several human infectious disease pathogens in England and Wales, highlighting those organisms that appear weather-sensitive and therefore may be influenced by climate change in the future.

Methods: Data on infections in England and Wales from 1989 to 2014 were extracted from the Public Health England (PHE) SGSS surveillance database. We conducted a weekly, monthly and quarterly time series analysis of 277 pathogen serotypes. Each organism's time series was forecasted using the TBATS package in R, with seasonality detected using model fit statistics. Meteorological data hosted on the MEDMI Platform were extracted at a monthly resolution for 2001-2011. The organisms were then clustered by K-means into two groups based on cross correlation coefficients with the weather variables.

Results: Examination of 12.9 million infection episodes found seasonal components in 91/277 (33%) organism serotypes. Salmonella showed seasonal and non-seasonal serotypes. These results were visualised in an online Rshiny application. Seasonal organisms were then clustered into two groups based on their correlations with weather. Group 1 had positive correlations with temperature (max, mean and min), sunshine and vapour pressure and inverse correlations with mean wind speed, relative humidity, ground frost and air frost. Group 2 had the opposite but also slight positive correlations with rainfall (mm, > 1 mm, > 10 mm).

Conclusions: The detection of seasonality in pathogen time series data and the identification of relevant weather predictors can improve forecasting and public health planning. Big data analytics and online visualisation allow the relationship between pathogen incidence and weather patterns to be clarified.
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http://dx.doi.org/10.1186/s12889-018-5931-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6114700PMC
August 2018

Association of Infant Eczema with Childhood and Adult Asthma: Analysis of Data from the 1958 Birth Cohort Study.

Int J Environ Res Public Health 2018 07 5;15(7). Epub 2018 Jul 5.

European Centre for Environment and Human Health, University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall TR1 3HD, UK.

The influence of early life exposures on later life disease has for some time provided clues to modifiable risk factors of disease. The “atopic march” is thought to play a role in the progression of allergic diseases and may offer an opportunity to lower asthma’s health and socioeconomic burden, although evidence remains controversial. We aimed to examine the relationship between early life eczema and asthma later in life. Using the National Child Development Study, we examined infant eczema and childhood and adult asthma. Data related to asthma or wheezing bronchitis were available for 13,503 (73%; 95% CI 72⁻74), 11,503 (61%; 95% CI 60⁻61), 12,524 (68%; 95% CI 67⁻69), 11,194 (60%; 95% CI 60⁻60), 9377 (51%; 95% CI 51⁻51), and 9760 (53%; 95% CI 52⁻53) subjects at ages 11, 16, 23, 33, 44, and 50 years, respectively. Logistic regression models were fitted to examine each wave separately before and after adjusting for a range of potential confounders. Generalised estimating equation (GEE) methods were undertaken to examine the associations after pooling all data from questionnaires. The prevalence of self-reported asthma in those that had previously reported infant eczema ranged from 1.0%; 95% CI 0.9⁻1.4 (age 44 years) to 2.2%; 95% CI 2.1⁻2.3 (age 33 years). Participants with infant eczema had a 2⁻3-fold increased risk of reporting asthma in childhood and adulthood; this was 1.6 times at age 44 years when using spirometry measures. Similar effect sizes were observed in the GEE models when considering all participants (OR 2.9; 95% CI 2.6⁻3.2). Childhood and adult asthma were consistently associated with infant eczema both by using the self-reported data and lung measures.
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http://dx.doi.org/10.3390/ijerph15071415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6069479PMC
July 2018

Healthy publics: enabling cultures and environments for health.

Palgrave Commun 2018 May;4:57

University of Exeter Medical School, Exeter, UK.

Despite extraordinary advances in biomedicine and associated gains in human health and well-being, a growing number of health and well-being related challenges have remained or emerged in recent years. These challenges are often 'more than biomedical' in complexion, being social, cultural and environmental in terms of their key drivers and determinants, and underline the necessity of a concerted policy focus on generating healthy societies. Despite the apparent agreement on this diagnosis, the means to produce change are seldom clear, even when the turn to health and well-being requires sizable shifts in our understandings of public health and research practices. This paper sets out a platform from which research approaches, methods and translational pathways for enabling health and well-being can be built. The term 'healthy publics' allows us to shift the focus of public health away from 'the public' or individuals as targets for intervention, and away from the view that culture acts as a barrier to efficient biomedical intervention, towards a greater recognition of the public struggles that are involved in raising health issues, questioning what counts as healthy and unhealthy and assembling the evidence and experience to change practices and outcomes. Creating the conditions for health and well-being, we argue, requires an engaged research process in which public experiments in building and repairing social and material relations are staged and sustained even if, and especially when, the fates of those publics remain fragile and buffeted by competing and often more powerful public formations.
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http://dx.doi.org/10.1057/s41599-018-0113-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5978671PMC
May 2018
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