Savings from the introduction of BPaL and BPaLM regimens at the country level.

BACKGROUND: In 2022, the WHO recommended the 6-month regimens BPaL (bedaquiline + pretomanid + linezolid) and BPaLM (BPaL + moxifloxacin) as treatment options for most forms of drug-resistant TB. SLASH-TB estimates the cost-saving and cost-effectiveness for the healthcare system and patients when a country switches from current standard-of-care treatment regimens to BPaL/BPaLM. METHODOLOGY: Country data from national TB programmes (NTP) are used to calculate the costs for all regimens and treatment outcomes. Where BPaL/BPaLM is not currently used, clinical trial outcomes data are used to estimate cost-effectiveness. DALYs are calculated using the Global Burden of Disease (GBD) database. RESULTS: We present the results of four countries that have used the tool and shared their data. When shorter and longer regimens are replaced with BPaL/BPaLM, the savings per patient treated in Pakistan, the Philippines, South Africa, and Ukraine are $746, $478, $757, and $2,636, respectively. An increased number of patients would be successfully treated with BPaL/BPaLM regimens, with 411, 1,025, 1,371 and 829 lives saved and 20,179, 27,443, 33,384 and 21,924 DALYs averted annually in the four countries, respectively. CONCLUSION: Through BPaL/BPaLM regimens, drug-resistant TB treatment has become more effective, shorter, less burdensome for patients, cheaper for both health systems and patients, and saves more lives.

CONTEXTE: En 2022, l'OMS a préconisé l'utilisation des schémas thérapeutiques (bedaquiline + pretomanid + linezolid) et BPaLM (BPaL + moxifloxacin), d'une durée de 6 mois, comme alternatives pour traiter la plupart des formes de TB résistante aux médicaments. SLASH-TB a réalisé une estimation des économies et de la rentabilité pour le système de santé et les patients lorsqu'un pays décide de passer des schémas thérapeutiques standards actuels au BPaL/BPaLM. MÉTHODOLOGIE: Les programmes nationaux de lutte contre la TB (NTP) utilisent les données nationales pour évaluer les coûts des différents schémas thérapeutiques et des résultats des traitements. Si le BPaL/BPaLM n'est pas utilisé actuellement, les données des essais cliniques sont utilisées pour estimer le rapport coût-efficacité. Les années de vie ajustées sur l'incapacité (DALYs, pour l'anglais « disability-adjusted life-years ¼) sont calculées à l'aide de la base de données Global Burden of Disease (GBD). RÉSULTATS: Nous présentons les résultats de quatre pays qui ont utilisé l'outil et partagé leurs données. Lorsque les schémas plus courts et plus longs sont remplacés par BPaL/BPaLM, les économies par patient traité au Pakistan, aux Philippines, en Afrique du Sud et en Ukraine sont respectivement de 746, 478, 757 et 2 636 dollars. L'utilisation des schémas BPaL/BPaLM permettrait de traiter un plus grand nombre de patients avec succès, ce qui sauverait respectivement 411, 1 025, 1 371 et 829 vies et éviterait 20 179, 27 443, 33 384 et 21 924 DALYs par an dans les quatre pays. CONCLUSION: Les schémas BPaL/BPaLM ont révolutionné le traitement de la tuberculose pharmacorésistante en le rendant plus efficace, plus rapide, moins contraignant pour les patients, plus économique pour les systèmes de santé et les patients, et en sauvant un plus grand nombre de vies.

Analysis of outcome using a levator sparing technique of abdominoperineal excision of rectum and anus. Cylindrical ELAPE is not necessary in all patients.

AIMS: Abdominoperineal excision of rectum (APE) for cancer has a higher rate of local recurrence with a poorer outcome than stage matched anterior resection. The cylindrical excision (ELAPE) has been advocated to reduce local recurrence. However, this operation has greater morbidity and requires more post operative care. We report our outcomes from a single centre using a levator sparing dissection. METHODS: All patients undergoing APE from January 2007-June 2011 were evaluated. Case notes operation notes and pathology results were reviewed for complications and staging. Follow-up data for survival and recurrence were obtained from the cancer registry, imaging and from clinic follow up. RESULTS: Of all rectal cancers (n = 361), 43 had APE with curative intent. Median age was 67(IQR 59-76). Median tumour height was two centimetres from the dentate line (IQR 1-3.5 cm). Neoadjuvant chemoradiotherapy was given in 98% of APE resections with curative intent. Median post operative hospital stay was 10 days (8-15). At a median follow up of 38 months (IQR30-49) for patients undergoing curative resection, 2 patients (4.6%) had local recurrence and overall mortality was 18.6% (n = 8). CONCLUSION: With adequate neoadjuvant chemoradiotherapy, a levator sparing excision of rectum remains a safe option with less morbidity and perioperative complications than has been described for ELAPE.

What can ecological data tell us about reasons for divergence in health status between West Central Scotland and other regions of post-industrial Europe?

BACKGROUND: The link between the effects of de-industrialization (unemployment, poverty) and population health is well understood. Post-industrial decline has, therefore, been cited as an underlying cause of high mortality in Scotland's most de-industrialized region. However, previous research showed other comparably de-industrialized regions in Europe to have better and faster improving health (with, in many cases, a widening gap evident from the early to mid-1980s). OBJECTIVES: To explore whether ecological data can provide insights into reasons behind the poorer, and more slowly improving, health status of West Central Scotland (WCS) compared with other European regions that have experienced similar histories of post-industrial decline. Specifically, this study asked: (1) could WCS's poorer health status be explained purely in terms of socio-economic factors (poverty, deprivation etc.)? and (2) could comparisons with other health determinant information identify important differences between WCS and other regions? These aims were explored alongside other research examining the historical, economic and political context in WCS compared with other de-industrialized regions. STUDY DESIGN AND METHODS: A range of ecological data, derived from surveys and routine administrative sources, were collected and analysed for WCS and 11 other post-industrial regions. Analyses were underpinned by the collection and analysis of more detailed data for four particular regions of interest. In addition, the project drew on accompanying literature-based research, analysing important contextual factors in de-industrialized regions, including histories of economic and welfare policies, and national and regional responses to de-industrialization. RESULTS: The poorer health status of WCS cannot be explained in terms of absolute measures of poverty and deprivation. However, compared with other post-industrial regions in Mainland Europe, the region is distinguished by having wider income inequalities and associated social characteristics (e.g. more single adults, lone parent households, higher rates of teenage pregnancy). Some of these distinguishing features are shared by other UK post-industrial regions which experienced the same economic history as WCS. CONCLUSION: From the collection of data and supporting analyses of important contextual factors, one can argue that poor health in WCS can be attributed to three layers of causation: the effects of de-industrialization (which have impacted on health in all post-industrial regions); the impact of 'neoliberal' UK economic policies, resulting in wider inequalities in WCS and the other UK regions; and an as-yet-unexplained (but under investigation) set of factors that cause WCS to experience worse health outcomes than similar regions within the UK.

Epidemiology of hospitalization due to alcohol-related harm: evidence from a Scottish cohort study.

OBJECTIVE: To examine a broad range of risk factors and their association with alcohol-related hospital admissions in a Scottish general population. DESIGN: Observational record-linkage study in Scotland from 1998 to 2008 involving 8305 respondents aged 16-74 years who participated in the 1998 Scottish Health Survey. Outcome was defined as first-time hospital admission with at least one alcohol-related diagnosis. METHODS: Cox proportional hazards modelling was applied to estimate the hazard ratio (HR) of first-time hospitalization with an alcohol-related condition associated with a range of behavioural, social and biological risk factors. FINDINGS: In total, 287 (3.4%) respondents experienced at least one alcohol-related hospitalization during the observation period. Moderate to excessive drinking was the strongest predictor of subsequent admission to hospital with an alcohol-related diagnosis, with clear evidence of a dose - response relationship. Moderate and heavy smoking were also significant predictors of subsequent admission to hospital with an alcohol-related problem. Social factors - such as being in receipt of income-related benefits [HR 1.68, 95% confidence interval (CI) 1.25-2.28]; being retired or economically inactive; and being separated, divorced or widowed (HR 2.34, 95% CI 1.70-3.22) - were also significant predictors of alcohol-related hospitalization. CONCLUSIONS: Moderate and higher levels of weekly alcohol consumption, moderate to heavy smoking, economic circumstances and marital status are the main risk factors for alcohol-related hospitalization in the Scottish population. These findings add to the evidence that population-based strategies are needed to limit alcohol-related morbidity.

Making the case for a 'fifth wave' in public health.

This paper will argue that the UK has seen several phases of public health improvement since the Industrial Revolution, and that each of these can be linked to major shifts in thinking about the nature of society and health itself. The authors are not, however, attempting to delineate firm sequences of events (or imply causality) as this would require a level of analysis of the relationship between economy, society and culture which is beyond the scope of this paper. Rather, it is suggested that each phase of health improvement can be thought of in metaphorical terms as a 'wave'. The first wave is associated with great public works and other developments arising from social responses to the profound disruptions which followed the Industrial Revolution. The second wave saw the emergence of medicine as science. The third wave involved the redesign of our social institutions during the 20th Century and gave birth to the welfare state. The fourth wave has been dominated by efforts to combat disease risk factors and the emergence of systems thinking. Although a trough of public health activity continues from each wave, none exerts the same impact as when it first emerged. This paper will discuss the complex challenges of obesity, inequality and loss of wellbeing, together with the broader problems of exponential growth in population, money creation and energy usage. As exponential growth is unsustainable on a finite planet, inevitable change looms. Taken together, these analyses suggest that a fifth wave of public health development is now needed; one which will need to differ radically from its forerunners. The authors invite others to join them in envisioning its nature and in furthering the debate about future public health.

Enabling well-being in a time of radical change: Integrative public health for the 21st century.

We live in a rapidly changing world; one where existing models for and approaches to health appear to deliver diminishing returns, whilst new public health challenges emerge. This paper outlines an integrative approach to such challenges. Integral theory suggests that key dimensions of human experience, frequently presented in opposition to each other (e.g. subjective-objective; individual-collective), need to be understood as integral to the whole. This is relevant to the public health community because powerful forces within neglected dimensions can undermine or destroy our efforts in other dimensions. This is illustrated in this paper by focusing on the issue of well-being, which illustrates the interconnected ways in which people in affluent societies can suffer from particular problems arising in such society and contribute to broader, global problems. The integral framework is used to show how a more integrative approach to such challenges can transcend some neglected blind-spots within public health. It is argued that public health leaders and practitioners need to apply integrative forms of thinking to their own practice in order to respond more effectively to the complexity of contemporary public health problems.

It's not 'just deprivation': why do equally deprived UK cities experience different health outcomes?

BACKGROUND: The link between deprivation and health is well established. However, recent research has highlighted the existence of a 'Scottish effect', a term used to describe the higher levels of poor health experienced in Scotland over and above that explained by socio-economic circumstances. Evidence of this 'excess' being concentrated in West Central Scotland has led to discussion of a more specific 'Glasgow effect'. However, within the UK, Glasgow is not alone in experiencing relatively high levels of poor health and deprivation; Liverpool and Manchester are two other cities which also stand out in this regard. Previous analyses of this 'effect' were also constrained by limitations of data and geography. OBJECTIVES: To establish whether there is evidence of a so-called 'Glasgow effect': (1) even when compared with its two most similar and comparable UK cities; and (2) when based on a more robust and spatially sensitive measure of deprivation than was previously available to researchers. STUDY DESIGN AND METHODS: Rates of 'income deprivation' (a measure very highly correlated with the main UK indices of multiple deprivation) were calculated for small areas (average population size: 1600) in Glasgow, Liverpool and Manchester. All-cause and cause-specific standardized mortality ratios were calculated for Glasgow relative to Liverpool and Manchester, standardizing for age, gender and income deprivation decile. In addition, a range of historical census and mortality data were analysed. RESULTS: The deprivation profiles of Glasgow, Liverpool and Manchester are almost identical. Despite this, premature deaths in Glasgow are more than 30% higher, with all deaths approximately 15% higher. This 'excess' mortality is seen across virtually the entire population: all ages (except the very young), both males and females, in deprived and non-deprived neighbourhoods. For premature mortality, standardized mortality ratios tended to be higher for the more deprived areas (particularly among males), and approximately half of 'excess' deaths under 65 years of age were directly related to alcohol and drugs. Analyses of historical data suggest that it is unlikely that the deprivation profile of Glasgow has changed significantly relative to Liverpool and Manchester in recent decades; however, the mortality gap appears to have widened since the early 1970s, indicating that the 'effect' may be a relatively recent phenomenon. CONCLUSION: While deprivation is a fundamental determinant of health and, therefore, an important driver of mortality, it is only one part of a complex picture. As currently measured, deprivation does not explain the higher levels of mortality experienced by Glasgow in relation to two very similar UK cities. Thus, additional explanations are required.

How will area regeneration impact on health? Learning from the GoWell study.

OBJECTIVES: To establish the theoretical and perceived links between area regeneration and health in a Scottish context in order to inform a comprehensive evaluation of regeneration activity. The evaluation will include health outcomes. STUDY DESIGN: Mixed method combining and comparing key informant interviews with policy analysis. METHODS: Analysis of identified links between elements of regeneration activity and health was undertaken of published policies and strategies which described regeneration for Scotland and the city of Glasgow. Interviews with key informants explored their understanding of the inputs to regeneration, and the pathways between regeneration and better health outcomes. RESULTS: The policy analysis and interviews revealed a holistic approach to a complex problem. Both identified a need for action to improve housing, neighbourhoods and services, education, employment, community participation and social issues. Improved health was identified as an emergent property. Interviewees identified a need to augment the established structural components with a more person-centred approach, fostering confidence and higher aspirations, but were uncertain how to achieve this. The interviews revealed a lack of confidence that current practice would deliver all the components of the holistic model. CONCLUSIONS: A holistic model of regeneration appears to inform policy, but is proving difficult to deliver. Improved health and reduced health inequalities were not primary objectives but emergent properties. In light of this, the ability of regeneration to actively maximize positive health impacts, particularly if this requires focused planning or opportunity costs to other activities, is questioned.

What can health professionals contribute to the challenge of sustainability?

Just as doctors have led aspects of social change in the past, health professionals today must contribute to and lead actions on sustainability. Exponential growth and unsustainability can be observed in the global population, energy use, money supply and greenhouse gas emissions. As with all unsustainable systems, they will become sustainable, but the timing and manner are undecided and carry profound health threats. We are trapped using outmoded forms of thinking and by our cognitive dissonance as we consider these threats in the light of our own lifestyles. The aim should be a transition that will lessen inequalities, combat problems such as obesity, depression and addictive behaviours, and improve well-being. The challenge is similar to other major public health issues in that the problem needs to be identified, evidence gathered, theories developed, alliances built, policies formulated and actions taken. This paper outlines how this can be done but suggests that the response needed will be unprecedented, and calls for action on what is known and debate about what is uncertain.

Can primary care reduce inequalities in mental health?

OBJECTIVES: To explore the contributions that primary care could make to reducing and preventing inequalities in mental health through policy, local strategy and practice. STUDY DESIGN: The study used an interpretive policy analysis framework to investigate the ways in which inequalities in mental health and inequalities in health were interpreted by health and social policies, incorporated into a local strategic process in a primary care organization, and understood and acted upon by frontline primary care and mental health practitioners. The study involved analysis of nine health and social policy documents, observation of a mental health needs assessment process, and interviews with 21 frontline professionals from 14 different disciplines. METHODS: Data were collected using document analysis, observation, and interviews with frontline staff which included a vignette. Data were sorted using the Atlas-ti software programme, and a grounded theory approach guided the data collection and analysis. RESULTS: Policy documents demonstrated a disjointed picture of definitions and actions, and lacked a clear overall interpretation of inequalities in health or inequalities in mental health. The mental health needs assessment did not incorporate discussion about inequalities in mental health, despite some individual steering group members demonstrating concerns about inequalities in mental health. Frontline professionals defined inequalities as being linked to access to health services rather than social factors, and were often uncomfortable about discussing inequalities in mental health. A small minority suggested that they would explore or take action on the social circumstances of a patient presenting with potential mental health problems. CONCLUSIONS: The study found that policies were not driving practice for reducing inequalities in mental health within primary care, and the primary care organization studied was not conducive to addressing inequalities in mental health. However, some building blocks were in place at all levels that have the potential to be developed to enable primary care to address inequalities in mental health.

Peak oil: will it be public health's greatest challenge?

The health of populations is determined more by the social and economic determinants of health than by changes in technology, health services or short-term policy interventions. In the near future, there is likely to be a significant shortfall in energy supply, resulting in high energy prices and a reversal of many of the aspects of globalization that are currently taken for granted. If this happens, economic recession and restructuring could have a negative impact on health, not dissimilar to that experienced by the former Soviet Union when it attempted a rapid change in its economy. There is, however, the potential, through economic planning and sustainable development, to reduce the adverse effects of this change and use this opportunity to impact on a range of diseases which are, at least in part, caused by overconsumption, inequality and loss of community.

Climate change and rising energy costs will change everything: a new mindset and action plan for 21st century public health.

Western governments currently prioritize economic growth and the pursuit of profit above alternative goals of sustainability, health and equality. Climate change and rising energy costs are challenging this consensus. The realization of the transformation required to meet these challenges has provoked denial and conflict, but could lead to a more positive response which leads to a health dividend; enhanced well-being, less overconsumption and greater equality. This paper argues that public health can make its best contribution by adopting a new mindset, discourse, methodology and set of tasks.

Climate change and rising energy costs: a threat but also an opportunity for a healthier future?

Health problems caused by overconsumption, growing inequalities and diminished well-being are issues that have been attributed to the prioritization of economic growth as the central purpose of society. It is also known that climate change and rising energy prices will inevitably bring changes to the globe's economic models. Doctors and the wider public health community have campaigned successfully in the past on issues such as the threat of nuclear war. Is it now time for this constituency to make its distinctive contribution to these new threats to health?

Cognitive aging: activity patterns and maintenance intentions.

This study examined relationships between cognitive functioning in older people and (1) levels of mental, physical and social activities, and (2) intentions regarding maintenance of cognitive functioning. Participants (N=145) were 70-91 years of age, varied in health status and socio-economic backgrounds. Current cognitive functioning was assessed by psychometric tests and real world problem solving tasks. Crystallized ability was indexed by the National Adult Reading Test (NART). Degree of involvement in mentally demanding activities was positively related to a fluid cognitive factor after effects of age, prior functioning, gender, health, and socio-economic status were accounted for. Social and physical activities were not related to the cognitive measures. Age effects on cognitive functioning were reduced among participants who reported undertaking activities intentionally to maintain cognitive functioning.

Real-world problem solving and quality of life in older people.

OBJECTIVES: This study examined relationships between quality of life (QoL) in older people and cognitive functioning in both abstract and real-world problem solving. DESIGN: Contributions of levels of mental, physical and social activities, self-rated and objective health status, self-rated cognitive functioning, socio-economic status, gender, real-world and abstract problem solving were examined in a regression study of factors related to QoL in older people. METHOD: Participants (N=145) were 70-91 years of age. The current cognitive functioning was assessed by psychometric tests and real-world problem-solving tasks. Prior functioning was indexed by crystallized ability measures. QoL was assessed using the Leiden-Padua questionnaire (LEIPAD), Faces scales and Hospital and Anxiety Depression Scale. A single QoL factor was derived. RESULTS: Simultaneous multiple regressions indicated that QoL was related to real-world but not to abstract problem-solving ability. Separate contributions to QoL were also found for health and self-rated cognitive functioning. CONCLUSIONS: The present study replicates previous findings that abstract problem-solving ability is not related to QoL and supports the hypothesis that real-world or everyday problem-solving ability is associated with QoL in older people.

An analysis of the link between behavioural, biological and social risk factors and subsequent hospital admission in Scotland.

OBJECTIVE: To determine the association between risk factors and hospital admission. METHODS: The 1998 Scottish Health Survey was linked to the Scottish hospital admission database. FINDINGS: Smoking was the most important behavioural risk factor (hazard ratio: 1.90, 95% CI: 1.59-2.27). Other behavioural risk factors yielded small but largely anticipated results. Hazard ratios for biological risks increased predictably but with some exceptions (blood pressure and total cholesterol). The top quintile for C-reactive protein showed almost double the risk of admission compared with the bottom quintile (hazard ratio: 1.93, 95% CI: 1.52-2.46). Elevated body mass index (BMI) increased the risk of serious admission (hazard ratio: 1.23, 95% CI: 1.03-1.47) and raised gamma-GT increased this risk by 20% (hazard ratio: 1.20, 95% CI: 1.04-1.38). Forced expiratory volume was the 'biological' factor with the largest risk (hazard ratio for lowest category: 1.82, 95% CI: 1.49-2.22). All the measures of social position showed variable effects on the risk of hospital admission. Large effects on risk were associated with self assessed health, longstanding illness and previous admission. CONCLUSION: The linkage of national surveys with a prospective hospitalization database will develop into an increasingly powerful tool.

Successful ageing in an area of deprivation: part 2--a quantitative exploration of the role of personality and beliefs in good health in old age.

OBJECTIVES: This paper presents further analysis of a study aimed at examining the determinants of good health and successful ageing in an area of deprivation. In this paper we report findings from the quantitative data related to two of the original eight research questions: (1) To what extent can health in old age be attributed to psychological/personality variables? and (2) What is the role of religious beliefs and 'spirituality' in healthy ageing? STUDY DESIGN: In-depth interview study in which standardized measures of personality and beliefs were administered, along with measures of beliefs devised for the study. METHODS: One hundred matched pairs of healthy and unhealthy 'agers' were interviewed face-to-face. Healthy ageing was assessed in terms of hospital morbidity and self-reported health. The sample comprised 106 males and 94 females (53 male matched pairs and 47 female matched pairs) ranging in age from 70 to 90 years of age with the majority (n=165) falling into the 71-80 age group and the remaining 35 in the 81-90 age group. All study participants were survivors of the Paisley/Renfrew (MIDSPAN) survey, a longitudinal study commenced in 1972 with continuous recording of morbidity and mortality since. Questionnaires assessing extraversion, neuroticism, psychoticism, health locus of control, sense of coherence, optimism, and religiosity were filled in by participants during the interviews. RESULTS: Compared to the unhealthy group, the healthy participants were less neurotic, more likely to endorse an internal locus of control belief and less likely to endorse a powerful others locus of control belief, and to report a greater sense of coherence. The unhealthy group scored higher on the religiosity/spirituality measure devised for this study. CONCLUSIONS: The findings are interesting in that, although they cannot address the issue of cause and effect, the very fact that the personality traits measured in this study were linked to health status in old age, further strengthens the argument that in general practice and hospital settings, an understanding of personality aids practitioners in dealing with patients. Finally, with the growing body of evidence that personality traits have a high degree of heritability, the routine gathering of information on personality traits would aid epidemiologists in their understanding of the determinants of healthy and successful ageing.

Successful ageing in an area of deprivation: part 1--a qualitative exploration of the role of life experiences in good health in old age.

OBJECTIVES: To determine the life histories and current circumstances of healthy and unhealthy older people who share an ecology marked by relative deprivation and generally poor health. STUDY DESIGN: In-depth interview study with a qualitative analysis. METHODS: Matched pairs of healthy and unhealthy 'agers' were interviewed face-to-face. Healthy ageing was assessed in terms of hospital morbidity and self-reported health. Study participants consisted of 22 pairs (44 individuals), aged 72-89 years, matched for sex, age and deprivation category, and currently resident in the West of Scotland. All study participants were survivors of the Paisley/Renfrew (MIDSPAN) survey, a longitudinal study commenced in 1972 with continuous recording of morbidity and mortality since. Detailed life histories were obtained which focused on family, residence, employment, leisure and health. This information was supplemented by more focused data on 'critical incidents', financial situation and position in social hierarchies. RESULTS: Data provided rich insights into life histories and current circumstances but no differences were found between healthy and unhealthy agers. CONCLUSIONS: It is important to understand what differentiates individuals who have lived in circumstances characterized by relative deprivation and poor health, yet have aged healthy. This study collected rich and detailed qualitative data. Yet, no important differences were detected between healthy and unhealthy agers. This is an important negative result as it suggests that the phenomenon of healthy ageing and the factors that promote healthy ageing over a lifetime are so complex that they will require even more detailed studies to disentangle.

Getting strategic about the environment and health.

Historically, the physical environment has been a target for public health policy across the globe. This remains the case in developing countries where the enduring infectious and toxic challenge posed by the environment is tangible and its health impact is manifest. However, in Western societies, the relevance of the environment to health has become obscured. Even when this is not the case, the perspective is usually narrow, centering on specific toxic, infectious or allergenic agents in particular environmental compartments. It is rare for importance to be given to a health-determining role for the environment acting through broader psychosocial mechanisms. The result is that environmental manipulation is seen as a cornerstone of the public health response for comparatively few health concerns. This paper considers how public health policies and action on the physical environment may be pursued more optimally. The need for a more strategic approach, which employs a new conceptual model that recognizes the complexity and contextual issues affecting the relationship between the environment and health but retains sufficient flexibility and simplicity to have practical application, is identified. Building on recent work, a model is proposed and pointers are given for its use in a practical context.