GroundsWell: Community-engaged and data-informed systems transformation of Urban Green and Blue Space for population health - a new initiative.

Natural environments, such as parks, woodlands and lakes, have positive impacts on health and wellbeing. Urban Green and Blue Spaces (UGBS), and the activities that take place in them, can significantly influence the health outcomes of all communities, and reduce health inequalities. Improving access and quality of UGBS needs understanding of the range of systems (e.g. planning, transport, environment, community) in which UGBS are located. UGBS offers an ideal exemplar for testing systems innovations as it reflects place-based and whole society processes , with potential to reduce non-communicable disease (NCD) risk and associated social inequalities in health. UGBS can impact multiple behavioural and environmental aetiological pathways. However, the systems which desire, design, develop, and deliver UGBS are fragmented and siloed, with ineffective mechanisms for data generation, knowledge exchange and mobilisation. Further, UGBS need to be co-designed with and by those whose health could benefit most from them, so they are appropriate, accessible, valued and used well. This paper describes a major new prevention research programme and partnership, GroundsWell, which aims to transform UGBS-related systems by improving how we plan, design, evaluate and manage UGBS so that it benefits all communities, especially those who are in poorest health. We use a broad definition of health to include physical, mental, social wellbeing and quality of life. Our objectives are to transform systems so that UGBS are planned, developed, implemented, maintained and evaluated with our communities and data systems to enhance health and reduce inequalities. GroundsWell will use interdisciplinary, problem-solving approaches to accelerate and optimise community collaborations among citizens, users, implementers, policymakers and researchers to impact research, policy, practice and active citizenship. GroundsWell will be shaped and developed in three pioneer cities (Belfast, Edinburgh, Liverpool) and their regional contexts, with embedded translational mechanisms to ensure that outputs and impact have UK-wide and international application.

Explaining inequalities in fruit and vegetable intake in Europe: The role of capabilities, opportunities and motivations.

People who do not eat enough fruit and vegetables (F&V) have incremental health risks. Most Europeans do not comply with health recommendations relating to F&V consumption and this is especially true for those with lower-level education, which reinforces structural inequalities in health and wellbeing among Europeans. This study investigated the role of key behavioural triggers - capabilities, opportunities and motivation (in the COM-B model) - as pathways for educational differentials in F&V intake in Europe. A cross-sectional survey-based study was conducted in five European countries differing widely in their consumption habits, wealth, and climatic conditions. A structural equation model was designed to study how capabilities (diet perceived knowledge, health purchase criteria), opportunities (financial availability, social norms), and motivations (health value, habits strength) affect educational inequalities in the intake of F&V (5 portions a day) as mediators. Multi-group comparisons assessed country differences. People with higher levels of education were more likely to eat the recommended diet, i.e., at least 5 portions of F&V a day. Countries in the sample vary significantly in the percentage of people complying with the recommendation, but not significantly in terms of relative education differentials. The educational gap in the intake of F&V is mainly explained by education differentials in financial availability, diet knowledge, and habits in inserting F&V in main meals. Policies targeting dietary inequalities should address behavioural triggers affecting dietary intake, for example by subsidising F&V, developing targeted dietary awareness campaigns, or by intervening in mass catering contexts to facilitate the implementation of healthy habits.

Fostering Engagement With Health and Housing Innovation: Development of Participant Personas in a Social Housing Cohort.

BACKGROUND: Personas, based on customer or population data, are widely used to inform design decisions in the commercial sector. The variety of methods available means that personas can be produced from projects of different types and scale. OBJECTIVE: This study aims to experiment with the use of personas that bring together data from a survey, household air measurements and electricity usage sensors, and an interview within a research and innovation project, with the aim of supporting eHealth and eWell-being product, process, and service development through broadening the engagement with and understanding of the data about the local community. METHODS: The project participants were social housing residents (adults only) living in central Cornwall, a rural unitary authority in the United Kingdom. A total of 329 households were recruited between September 2017 and November 2018, with 235 (71.4%) providing complete baseline survey data on demographics, socioeconomic position, household composition, home environment, technology ownership, pet ownership, smoking, social cohesion, volunteering, caring, mental well-being, physical and mental health-related quality of life, and activity. K-prototype cluster analysis was used to identify 8 clusters among the baseline survey responses. The sensor and interview data were subsequently analyzed by cluster and the insights from all 3 data sources were brought together to produce the personas, known as the Smartline Archetypes. RESULTS: The Smartline Archetypes proved to be an engaging way of presenting data, accessible to a broader group of stakeholders than those who accessed the raw anonymized data, thereby providing a vehicle for greater research engagement, innovation, and impact. CONCLUSIONS: Through the adoption of a tool widely used in practice, research projects could generate greater policy and practical impact, while also becoming more transparent and open to the public.

Encouraging and Enabling Lifestyles and Behaviours to Simultaneously Promote Environmental Sustainability, Health and Equity: Key Policy Messages from INHERIT.

Human consumption and activity are damaging the global ecosystem and the resources on which we rely for health, well-being and survival. The COVID-19 crisis is yet another manifestation of the urgent need to transition to more sustainable societies, further exposing the weaknesses in health systems and the injustice in our societies. It also underlines that many of the factors leading to environmental degradation, ill health and social and health inequities are interlinked. The current situation provides an unprecedented opportunity to invest in initiatives that address these common factors and encourage people to live more healthily and sustainably. Such initiatives can generate the positive feedback loops needed to change the systems and structures that shape our lives. INHERIT (January 2016-December 2019), an ambitious, multisectoral and transnational research project that involved 18 organisations across Europe, funded by the European Commission, explored such solutions. It identified, defined and analysed promising inter-sectoral policies, practices and approaches to simultaneously promote environmental sustainability, protect and promote health and contribute to health equity (the INHERIT "triple-win") and that can encourage and enable people to live, move and consume more healthfully and sustainably. It also explored the facilitators and barriers to working across sectors and in public private cooperation. The insights were brought together in guidelines setting out how policy makers can help instigate and support local "triple-win" initiatives that influence behaviours as an approach to contributing to the change that is so urgently needed to stem environmental degradation and the interlinked threats to health and wellbeing. This article sets out this guidance, providing timely insights on how to "build back better" in the post pandemic era.

How to Achieve a Healthier and More Sustainable Europe by 2040 According to the Public? Results of a Five-Country Questionnaire Survey.

The aim of this paper is to understand public preferences for several future scenarios of achieving a healthier, more equitable and sustainable Europe, which differ in the way the society is organized (individualistically vs. collectively) and in the driving sector (public vs. private). To achieve this aim, we conducted a questionnaire survey using representative samples for five European countries in 2018. About three thousand respondents chose among the four scenarios presented within four different contexts (green spaces, active mobility, energy-efficient housing, food consumption) or none of them. A majority of people in the five European countries were ready to accept one of the scenarios. We found significant differences in preferences according to socioeconomic backgrounds and values of respondents. People above 35 years old, those who were less educated, and those in the lowest household income tertile were less supportive of all scenarios. The heterogeneity in preferences associated with differences in socioeconomic backgrounds was larger for the scenario in which society is organized individualistically and driven by the private sector. Smaller distinctions were found in case of the scenario in which society is organized collectively and is driven by the public sector. Departing from social psychological theories, we examine the role of altruistic, biospheric, egoistic, hedonic, and security values. People with stronger biospheric values were more likely to accept scenarios, particularly those which are driven by the public sector and where there is more collective organisation. Those with a more egoistic value orientation were more likely to have higher preferences for scenarios where the private sector had a dominant role. The policy implications, in terms of the selection and framing of policy measures to enhance public support, are discussed.

Providing Access to Urban Green Spaces: A Participatory Benefit-Cost Analysis in Spain.

The opening up of green spaces could provide significant benefits to society. This study develops a framework to assess the economic benefits and costs of public interventions providing citizen access to urban green spaces. The Thinking Fadura project in Getxo (Spain) was used as a case study. A method for participatory benefit-cost analysis is developed, where a stakeholder-participatory evaluation is combined with a standard cost-benefit analysis. The participatory evaluation followed a bottom-up approach in a sequential evaluation including three main focal points: key stakeholders and experts, visitors and the general public. The assessment demonstrates that the Thinking Fadura project's benefits outweigh the costs. The results suggest that projects designed with the purpose of improving green space accessibility to the general public can be beneficial from a societal perspective. The highest economic benefits were an increase in the amenity and recreational value and an increase in people's physical activity. The participatory evaluation indicates that giving access to people of lower socio-economic status and vulnerable groups and improving recreational use were perceived as the most beneficial. An increase in noise, dirt, and risk of criminal activities as well as potential conflicts between green space users were perceived as the most negative impacts of opening a previously restricted area to the general public. The economic assessment of Thinking Fadura project could serve as a model in the decision-making process in locations where the use of greenspaces is restricted.

Ten Lessons for Good Practice for the INHERIT Triple Win: Health, Equity, and Environmental Sustainability.

The world's challenges of climate change, damage to ecosystems, and social and health inequalities require changes in human behaviours at every level of organisation, among governments, business, communities, and individuals. An important question is how behaviour change can be enabled and supported at the scale and speed required. The research reported in this paper describes important lessons for good practice in changing contexts to modify behaviours for a triple win for health, equity and environmental sustainability. Authors synthesised learning from qualitative, quantitative and cost benefit evaluations of 15 case studies conducted in 12 countries in Europe. The case studies address ways of living (green spaces and energy efficient housing), moving (active transport) and consuming (healthy and sustainable diets) that support the triple win. Ten lessons for good practice were identified. These include bringing a triple win mindset to policy and practice in planning interventions, with potential to improve environmental sustainability, health and equity at the same time. The lessons for good practice are intended to support governmental and non-governmental actors, practitioners and researchers planning to work across sectors to achieve mutual benefits for health and environmental sustainability and in particular to benefit poorer and more socio-economically disadvantaged groups.

A Technological Scenario for a Healthier, More Equitable and Sustainable Europe in 2040: Citizen Perceptions and Policy Implications.

This article aims at exploring, understanding and comparing European citizens' insights and perceptions towards "My life between realities", a positive future scenario which depicts a narrative of reaching healthier, more equitable and sustainable societies by 2040 with the support of technology and technological solutions. It responds to the need for gathering and incorporating more citizen insights into future policy developments and strategic actions to tackle the global challenge of unsustainable development. Citizens of five European countries-the Czech Republic, Germany, North Macedonia, Spain and the United Kingdom-have been consulted through focus groups. The exercise has uncovered citizens' preferences and attitudes towards four main lifestyle areas; namely, green spaces, energy efficient housing, active mobility and (food) consumption. The technological attributes of the scenario led to citizens expressing diametrically opposed and critical perceptions and attitudes. Given the prospects of technology in driving sustainable development, based on these insights, policy recommendations for the better integration and acceptance of technological advances by the public are discussed herein.

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

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

The Cost of Ménière's Disease: A Novel Multisource Approach.

OBJECTIVES: To estimate the annual cost of Ménière's disease and the cost per person in the UK population and to investigate the direct and indirect costs of the condition. DESIGN: The authors utilized a multidata approach to provide the first estimate of the cost of Ménière's. Data from the UK Biobank (a study of 500,000 individuals collected between 2007 and 2012), the Hospital Episode Statistics (data on all hospital admissions in England from 2008 to 2012) and the UK Ménière's Society (2014) were used to estimate the cost of Ménière's. Cases were self-reported in the UK Biobank and UK Ménière's Society, within the Hospital Episode Statistics cases were clinician diagnosed. The authors estimated the direct and indirect costs of the condition, using count data to represent numbers of individuals reporting specific treatments, operations etc. and basic statistical analyses (χ tests, linear and logistic regression) to compare cases and controls in the UK Biobank. RESULTS: Ménière's was estimated to cost between £541.30 million and £608.70 million annually (equivalent to US $829.9 to $934.2 million), equating to £3,341 to £3,757 ($5112 to $5748) per person per annum. The indirect costs were substantial, with loss of earnings contributing to over £400 million per annum. CONCLUSIONS: For the first time, the authors were able to estimate the economic burden of Ménière's disease. In the UK, the annual cost of this condition is substantial. Further research is required to develop cost-effective treatments and management strategies for Ménière's to reduce the economic burden of the disease. These findings should be interpreted with caution due to the uncertainties inherent in the analysis.

Mainstreaming carbon management in healthcare systems: a bottom-up modeling approach.

Increasing greenhouse gas emissions threaten human health and the environment. In response, healthcare managers face significant challenges in balancing operational decisions about patient care with carbon mitigation targets. We explore a bottom-up modeling framework to aid in the decision-making for both carbon and cost in healthcare, using data from a case study in Cornwall, UK. A model was built and run for secondary healthcare, specifically outpatient clinics, theater lists, beds, and diagnostic facilities. Five scenarios were tested: business-as-usual; service expansion; site closure; water temperature reduction; and theater optimization. The estimated emissions from secondary healthcare in Cornwall ran to 5787 T CO(2)eq with patient travel adding 2215 T CO(2)eq. Closing selected sites would have reduced this by 4% (261 T CO(2)eq), a reduction less than the resulting increases in patient transport emissions. Reducing hot water temperatures by 5 °C and improving theater usage would lower the footprint by 0.7% (44 T CO(2)eq) and 0.08% (5 T CO(2)eq), respectively. We consider bottom-up models important tools in the process of estimating and modeling the carbon footprint of healthcare. For the carbon reduction targets of the healthcare sector to be met, the use of these bottom-up models in decision making and forward planning is pivotal.

Assessment of the contributions of CYP3A4 and CYP3A5 in the metabolism of the antipsychotic agent haloperidol to its potentially neurotoxic pyridinium metabolite and effect of antidepressants on the bioactivation pathway.

As a plausible explanation for the large interindividual variability in the pharmacokinetics of the neuroleptic agent haloperidol, the contributions of CYP3A isozymes (CYP3A4 and the polymorphic CYP3A5) predominantly involved in haloperidol bioactivation to the neurotoxic pyridinium species 4-(4-Chlorophenyl)-1-[4-(4-fluorophenyl)-4-oxobutyl]-pyridinium (HPP(+)) were assessed in human liver microsomes and heterologously expressed enzymes. Based on recent reports on drug-drug interactions between haloperidol and antidepressants including selective serotonin reuptake inhibitors, the inhibitory effects of antidepressants on the CYP3A4/5-mediated haloperidol bioactivation were also evaluated. HPP(+) formation followed Michaelis-Menten kinetics in microsomes, recombinant CYP3A4, and CYP3A5 with K(m) values of 24.4 +/- 8.9 microM, 18.3 +/- 4.9 microM, and 200.2 +/- 47.6 microM, respectively, and V(max) values of 157.6 +/- 13.2 pmol/min/mg of protein, 10.4 +/- 0.6 pmol/min/pmol P450, and 5.16 +/- 0.6 pmol/min/pmol P450, respectively. The similarity in K(m) values between human liver microsomal and recombinant CYP3A4 incubations suggests that polymorphic CYP3A5 may not be an important genetic contributor to the interindividual variability in CYP3A-mediated haloperidol clearance pathways. Besides HPP(+), a novel 4-fluorophenyl-ring-hydroxylated metabolite of haloperidol in microsomes/CYP3A enzymes was also detected. Its formation was consistent with previous reports on the detection of O-sulfate and -glucuronide conjugates of a fluorophenyl ring-hydroxylated metabolite of haloperidol in human urine. Finally, all antidepressants except buspirone inhibited the CYP3A4/5-catalyzed oxidation of haloperidol to HPP(+) in a concentration-dependent manner. Based on the estimated IC(50) values for inhibition of HPP(+) formation in microsomes, the antidepressants were ranked in the following order: fluoxetine, nefazodone, norfluoxetine, trazodone, and fluvoxamine. These inhibition results suggest that clinically observed drug-drug interactions between haloperidol and antidepressants may arise via the attenuation of CYP3A4/5-mediated 4-(4-chlorophenyl)-1-[4-(4-fluorophenyl)-4-oxobutyl]-4-piperidinol biotransformation pathways.