Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation-Lancet Commission on planetary health

The Planetary Child Health & Enterics Observatory (Plan-EO): A protocol for an interdisciplinary research initiative and web-based dashboard for mapping enteric infectious diseases and their risk factors and interventions in LMICs

BACKGROUND

Diarrhea remains a leading cause of childhood illness throughout the world that is increasing due to climate change and is caused by various species of ecologically sensitive pathogens. The emerging Planetary Health movement emphasizes the interdependence of human health with natural systems, and much of its focus has been on infectious diseases and their interactions with environmental and human processes. Meanwhile, the era of big data has engendered a public appetite for interactive web-based dashboards for infectious diseases. However, enteric infectious diseases have been largely overlooked by these developments.

METHODS

The Planetary Child Health & Enterics Observatory (Plan-EO) is a new initiative that builds on existing partnerships between epidemiologists, climatologists, bioinformaticians, and hydrologists as well as investigators in numerous low- and middle-income countries. Its objective is to provide the research and stakeholder community with an evidence base for the geographical targeting of enteropathogen-specific child health interventions such as novel vaccines. The initiative will produce, curate, and disseminate spatial data products relating to the distribution of enteric pathogens and their environmental and sociodemographic determinants.

DISCUSSION

As climate change accelerates there is an urgent need for etiology-specific estimates of diarrheal disease burden at high spatiotemporal resolution. Plan-EO aims to address key challenges and knowledge gaps by making and disseminating rigorously obtained, generalizable disease burden estimates. Pre-processed environmental and EO-derived spatial data products will be housed, continually updated, and made publicly available for download to the research and stakeholder communities. These can then be used as inputs to identify and target priority populations living in transmission hotspots and for decision-making, scenario-planning, and disease burden projection.

STUDY REGISTRATION

PROSPERO protocol #CRD42023384709.

Environmental health knowledge and competences in Basque health workers. A comparison of different professional profiles

Environmental exposures are responsible for a quarter of morbidity and mortality rates globally. Primary care professionals work in a privileged position to detect and intervene on environmental health matters. Nevertheless, due to lack of specific training, international literature shows that primary care health professionals have limited skills to deal with those. The objectives of this study were to assess the levels of environmental health (EH) knowledge and competence of a sample of 446 health professionals and students in the Basque Country and explore the presence that EH has on their daily practice. Only a very small proportion of participants had received training and took environmental clinical history regularly. Participants were confident to deal, and actually dealt, with tobacco, pollen and sun exposures but less able to address topics like biomarkers, pesticides and endocrine disruptors. Finally, and in accordance to previous works, we found moderate levels of EH knowledge and skills in our sample, and observed that nurses and nursing students reported higher EH skills than other professional profiles but scored lower in knowledge. Despite the manifold impacts of environmental exposures on health, interventions to strengthen health professionals' EH competence are required.

Understanding nurses' experience of climate change and then climate action in Western Canada

AIM

To understand nurses' personal and professional experiences with the heat dome, drought and forest fires of 2021 and how those events impacted their perspectives on climate action.

DESIGN

A naturalistic inquiry using qualitative description.

METHOD

Twelve nurses from the interior of British Columbia, Canada, were interviewed using a semi-structured interview guide. Thematic analysis was employed. No patient or public involvement.

RESULTS

Data analysis yielded three themes to describe nurses' perspective on climate change: health impacts; climate action and system influences. These experiences contributed to nurses' beliefs about climate change, how to take climate action in their personal lives and their challenges enacting climate action in their workplace settings.

CONCLUSIONS

Nurses' challenges with enacting environmentally responsible practices in their workplace highlight the need for engagement throughout institutions in supporting environmentally friendly initiatives.

IMPACT

The importance of system-level changes in healthcare institutions for planetary health.

Health psychology and climate change: time to address humanity's most existential crisis

Climate change is an ongoing and escalating health emergency. It threatens the health and wellbeing of billions of people, through extreme weather events, displacement, food insecurity, pathogenic diseases, societal destabilisation, and armed conflict. Climate change dwarfs all other challenges studied by health psychologists. The greenhouse gas emissions driving climate change disproportionately originate from the actions of wealthy populations in the Global North and are tied to excessive energy use and overconsumption driven by the pursuit of economic growth. Addressing this crisis requires significant societal transformations and individual behaviour change. Most of these changes will benefit not only the stability of the climate but will yield significant public health co-benefits. Because of their unique expertise and skills, health psychologists are urgently needed in crafting climate change mitigation responses. We propose specific ways in which health psychologists at all career stages can contribute, within the spheres of research, teaching, and policy making, and within organisations and as private citizens. As health psychologists, we cannot sit back and leave climate change to climate scientists. Climate change is a health emergency that results from human behaviour; hence it is in our power and responsibility to address it.

Agency in the Anthropocene: education for planetary health

Collective action is essential to address planetary health as current and future environmental challenges are socioecological and require coordinated, informed, and sustained action from all societal sectors. Education that engages intergenerational communities is a crucial means of building collective action as it provides opportunities to develop an informed citizenry capable of making the necessary decisions to work towards planetary health. Schools are valuable sites of community learning and action, and will benefit from a new orientation towards and commitment to educator training, curriculum development, and youth agency. This orientation is supported by the Organisation for Economic Co-operation and Development's Programme for International Student Assessment's (PISA) 2025 Science Framework, which measures the competence (skills and knowledge) of 15-year-old students. This Personal View describes a new concept, Agency in the Anthropocene, a contributing element of the 2025 Science Framework that defines the way science education could develop agency and hope in this era of socioecological challenges that are impacting planetary health.

Die Dinosaurier und das Weltklima

Der Einschlag des im Durchmesser 14 km messenden Asteroiden vor 66 Millionen Jahren auf unserem Planeten kam urplötzlich – und hatte gravierende Folgen 1. Geologisch hinterließ er im Durchmesser den 180 km messenden Chicxulub-Krater auf der mexikanischen Halbinsel Yukatan, biologisch war er der Anfang vom Ende der Dinosaurier. Von diesen „schrecklichen Echsen“ (griechisch: „deinos sauros“) stammen die beindruckend großen Fossilien, welche heute in Naturkundemuseen weltweit zu bestaunen sind. Das mit diesem Ereignis verbundene Sterben von drei Vierteln aller Arten – nicht nur bei den Sauriern – als Folge eines globalen Winters und einer anschließenden anhaltenden Abkühlung erstreckte sich vermutlich über Tausende von Jahren. Es markierte den Übergang von der Kreidezeit in ein neues Erdzeitalter, welches insbesondere den Säugetieren neue ökologische Nischen zur weiteren erfolgreichen Entfaltung bot. Es war das fünfte massenhafte Artensterben innerhalb der letzten 500 Millionen Jahre gewesen. Deren Auslöser waren neben dem beschriebenen Asteroideneinschlag (Ereignis fünf) eine rasche alternierende Abfolge von Kalt- und Warmzeiten (Ereignis eins), eine globale Kaltzeit infolge der Besiedlung des Landes durch Pflanzen (Ereignis zwei), intensive vulkanische Aktivitäten mit Übersäuerung durch Kohlendioxid und Schwefelwasserstoffe zu Lande und zu Wasser (Ereignis drei) sowie tiefseeische Vulkanausbrüche mit globaler Erwärmung und chemischen Veränderungen in den Ozeanen (Ereignis vier) 2.

From Health-in-All-Policies to Climate-in-All-Policies: Using the Synergies between Health Promotion and Climate Protection to Take Action

The climate crisis is developing into a life-changing event on a global level. Health promotion with the aim to increase the health status of individuals, independent of the present health status, has been developed on a scientific basis at least for the last eight decades. There are some basic principles which are prerequisites for both health promotion and climate protection. Those principles include (1) sustainability, (2) orientation on determinants, and (3) requirement of individual as well as community approaches. People are generally aiming to protect their lifestyle habits (e.g., traveling and consumer habits) and personal property (e.g., car and house) with easy solutions and as little effort as possible, and this can affect both health and climate. To reduce the emission of greenhouse gases and to protect our environment, changes towards a sustainable lifestyle have to be embedded into everybody's mind. Examples for domains that need to be addressed in health promotion as well as in climate protection include (health and climate) literacy, physical activity and active mobility, and nutrition and dietary habits. If health promotion fails to tackle those domains, this will continue to drive the climate crisis. And climate change, in turn, will affect health. On the other hand, developing and promoting health resources in the domains mentioned could help to mitigate the health-damaging effects of climate change. Success in the joint efforts to promote health and protect the climate would improve the One Health approach, the health of people and the environment.

The effects of health-related food taxes on the environmental impact of consumer food purchases: secondary analysis of data from a randomised controlled trial in a virtual supermarket

OBJECTIVE

To measure the effects of health-related food taxes on the environmental impact of consumer food purchases in a virtual supermarket.

DESIGN

This is a secondary analysis of data from a randomised controlled trial in which participants were randomly assigned to a control condition with regular food prices (n 152), an experimental condition with a sugar-sweetened beverage (SSB) tax (n 131) or an experimental condition with a nutrient profiling tax based on Nutri-Score (n 112). Participants were instructed to undertake their typical weekly grocery shopping for their households. Primary outcome measures were three environmental impact indicators: greenhouse gas (GHG) emissions, land use and blue water use per household per week. Data were analysed using linear regression analyses.

SETTING

Three-dimensional virtual supermarket.

PARTICIPANTS

Dutch adults (≥ 18 years) who were responsible for grocery shopping in their household (n 395).

RESULTS

GHG emissions (-7·6 kg CO2-eq; 95 % CI -12·7, -2·5) and land use (-3·9 m2/year; 95 % CI -7·7, -0·2) were lower for the food purchases of participants in the nutrient profiling tax condition than for those in the control condition. Blue water use was not affected by the nutrient profiling tax. Moreover, the SSB tax had no significant effect on any of the environmental impact indicators.

CONCLUSIONS

A nutrient profiling tax based on Nutri-Score reduced the environmental impact of consumer food purchases. An SSB tax did not affect the environmental impact in this study.

Quality criteria of nature-based interventions in healthcare facilities: a scoping review

Introduction

Implementing integrated nature-based interventions that simultaneously serve human health and the restoration of biodiversity in healthcare facilities is considered a promising strategy. As an emerging field of research and practice in healthcare, identification of quality criteria is necessary to support desired outcomes related to biodiversity, human health and intervention processes. This study is part of a larger research project in collaboration with the Flemish Agency of Nature and Forest in Belgium.

Methods

A scoping review was conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews, in PubMed, Medline, Web of Science and Scopus. A step-by-step tabular screening process was conducted to identify relevant studies and reviews of nature-based interventions, published in English between January 2005 and April 2023. A qualitative content analysis was conducted and the results were then presented to the project steering group and a panel of stakeholders for refinement.

Results

After filtering on the eligibility criteria, and with focus on healthcare facilities, 14 articles were included in this study. A preliminary nature-based interventions quality framework with a set of quality indicators has been developed.

Discussion

When designing integrated nature-based interventions, a needs analysis of users and the outdoor environment should be conducted. Next, the integration of a One Health and biodiversity perspective and the application of a complex intervention framework, could support the quality of the design and implementation of nature-based interventions in healthcare facilities and facilitate their assessment. In future work, more rigorous research into the design and implementation of integrated nature-based interventions is needed to test and refine the quality criteria in practice.

The Planetary Child Health & Enterics Observatory (Plan-EO): a protocol for an interdisciplinary research initiative and web-based dashboard for mapping enteric infectious diseases and their risk factors and interventions in LMICs

Background

Diarrhea remains a leading cause of childhood illness throughout the world that is increasing due to climate change and is caused by various species of ecologically sensitive pathogens. The emerging Planetary Health movement emphasizes the interdependence of human health with natural systems, and much of its focus has been on infectious diseases and their interactions with environmental and human processes. Meanwhile, the era of big data has engendered a public appetite for interactive web-based dashboards for infectious diseases. However, enteric infectious diseases have been largely overlooked by these developments.

Methods

The Planetary Child Health and Enterics Observatory (Plan-EO) is a new initiative that builds on existing partnerships between epidemiologists, climatologists, bioinformaticians, and hydrologists as well as investigators in numerous low- and middle-income countries. Its objective is to provide the research and stakeholder community with an evidence base for the geographical targeting of enteropathogen-specific child health interventions such as novel vaccines. The initiative will produce, curate, and disseminate spatial data products relating to the distribution of enteric pathogens and their environmental and sociodemographic determinants.

Discussion

As climate change accelerates there is an urgent need for etiology-specific estimates of diarrheal disease burden at high spatiotemporal resolution. Plan-EO aims to address key challenges and knowledge gaps by making rigorously obtained, generalizable disease burden estimates freely available and accessible to the research and stakeholder communities. Pre-processed environmental and EO-derived spatial data products will be housed, continually updated, and made publicly available to the research and stakeholder communities both within the webpage itself and for download. These inputs can then be used to identify and target priority populations living in transmission hotspots and for decision-making, scenario-planning, and disease burden projection.

Study registration

PROSPERO protocol #CRD42023384709.

Exploring the rise and diversity of health and societal issues that use a public health approach: A scoping review and narrative synthesis

There is an increase in calls across diverse issues for a "public health approach" however, it is not clear whether there is any shared understanding in approach in its conceptualisation or implementation. Our aims were to (1) identify and categorise the issues which discuss a public health approach within published literature since 2010, (2) chart the descriptions and applications of public health approaches across and within four purposively sampled categories of issues, and (3) capture any evaluations conducted. A scoping review of published literature was undertaken; Seven leading databases were searched: AMED, APA PsycInfo, ASSIA, CINAHL complete, Cochrane Library (Review), Embase, and MEDLINE for articles published between 2010 and 2022 which have applied, described or called for a "public health approach" to address any issue. 3,573 studies were identified through our initial searches, of these 1,635 articles were recognised for possible inclusion from analysis of titles and abstract. The final number of included studies was 1,314. We identified 28 categories, 26 of which were societal issues, where a public health approach is being advocated. We purposively selected four of these categories; adverse childhood experiences; end of life care; gambling addiction and violence reduction/ knife crime for further analysis of the approach including how it was conceptualised and operationalised; less than 13% of the studies described the implementation of a public health approach and there was considerable heterogeneity across and within categories as to how this was done. Since 2010 there have been increasing calls for a public health approach to be taken to address health and societal challenges. However, the operationalisation of a public health approach varied extensively and there were few evaluations of the approach. This has implications for policy makers and those involved in commissioning related approaches in the future as the evidence-base is limited.

The Planetary Child Health & Enterics Observatory (Plan-EO): a protocol for an interdisciplinary research initiative and web-based dashboard for mapping enteric infectious diseases and their risk factors and interventions in LMICs

Background

Diarrhea remains a leading cause of childhood illness throughout the world that is increasing due to climate change and is caused by various species of ecologically sensitive pathogens. The emerging Planetary Health movement emphasizes the interdependence of human health with natural systems, and much of its focus has been on infectious diseases and their interactions with environmental and human processes. Meanwhile, the era of big data has engendered a public appetite for interactive web-based dashboards for infectious diseases. However, enteric infectious diseases have been largely overlooked by these developments.

Methods

The Planetary Child Health and Enterics Observatory (Plan-EO) is a new initiative that builds on existing partnerships between epidemiologists, climatologists, bioinformaticians, and hydrologists as well as investigators in numerous low- and middle-income countries. Its objective is to provide the research and stakeholder community with an evidence base for the geographical targeting of enteropathogen-specific child health interventions such as novel vaccines. The initiative will produce, curate, and disseminate spatial data products relating to the distribution of enteric pathogens and their environmental and sociodemographic determinants.

Discussion

As climate change accelerates there is an urgent need for etiology-specific estimates of diarrheal disease burden at high spatiotemporal resolution. Plan-EO aims to address key challenges and knowledge gaps by making rigorously obtained, generalizable disease burden estimates freely available and accessible to the research and stakeholder communities. Pre-processed environmental and EO-derived spatial data products will be housed, continually updated, and made publicly available to the research and stakeholder communities both within the webpage itself and for download. These inputs can then be used to identify and target priority populations living in transmission hotspots and for decision-making, scenario-planning, and disease burden projection.

Study registration

PROSPERO protocol #CRD42023384709.

Assessing the Human Health Benefits of Climate Mitigation, Pollution Prevention, and Biodiversity Preservation

Background

Since the Industrial Revolution, humanity has amassed great wealth and achieved unprecedented material prosperity. These advances have come, however, at great cost to the planet. They are guided by an economic model that focuses almost exclusively on short-term gain, while ignoring natural capital and human capital. They have relied on the combustion of vast quantities of fossil fuels, massive consumption of the earth's resources, and production and environmental release of enormous quantities of chemicals, pesticides, fertilizers, and plastics. They have caused climate change, pollution, and biodiversity loss, the "Triple Planetary Crisis". They are responsible for more than 9 million premature deaths per year and for widespread disease - impacts that fall disproportionately upon the poor and the vulnerable.

Goals

To map the human health impacts of climate change, pollution, and biodiversity loss. To outline a framework for assessing the health benefits of interventions against these threats.

Findings

Actions taken by national governments and international agencies to mitigate climate change, pollution, and biodiversity loss can improve health, prevent disease, save lives, and enhance human well-being. Yet assessment of health benefits is largely absent from evaluations of environmental remediation programs. This represents a lost opportunity to quantify the full benefits of environmental remediation and to educate policy makers and the public.

Recommendations

We recommend that national governments and international agencies implementing interventions against climate change, pollution, and biodiversity loss develop metrics and strategies for quantifying the health benefits of these interventions. We recommend that they deploy these tools in parallel with assessments of ecologic and economic benefits. Health metrics developed by the Global Burden of Disease (GBD) study may provide a useful starting point.Incorporation of health metrics into assessments of environmental restoration will require building transdisciplinary collaborations. Environmental scientists and engineers will need to work with health scientists to establish evaluation systems that link environmental and economic data with health data. Such systems will assist international agencies as well as national and local governments in prioritizing environmental interventions.

Emerging and re-emerging pediatric viral diseases: a continuing global challenge

The twenty-first century has been marked by a surge in viral epidemics and pandemics, highlighting the global health challenge posed by emerging and re-emerging pediatric viral diseases. This review article explores the complex dynamics contributing to this challenge, including climate change, globalization, socio-economic interconnectedness, geopolitical tensions, vaccine hesitancy, misinformation, and disparities in access to healthcare resources. Understanding the interactions between the environment, socioeconomics, and health is crucial for effectively addressing current and future outbreaks. This scoping review focuses on emerging and re-emerging viral infectious diseases, with an emphasis on pediatric vulnerability. It highlights the urgent need for prevention, preparedness, and response efforts, particularly in resource-limited communities disproportionately affected by climate change and spillover events. Adopting a One Health/Planetary Health approach, which integrates human, animal, and ecosystem health, can enhance equity and resilience in global communities. IMPACT: We provide a scoping review of emerging and re-emerging viral threats to global pediatric populations This review provides an update on current pediatric viral threats in the context of the COVID-19 pandemic This review aims to sensitize clinicians, epidemiologists, public health practitioners, and policy stakeholders/decision-makers to the role these viral diseases have in persistent pediatric morbidity and mortality.

Just-relations and responsibility for planetary health: The global nurse agenda for climate justice

There is an urgent call for nurses to address climate change, especially in advocating for those most under threat to the impacts. Social justice is important to nurses in their relations with individuals and populations, including actions to address climate justice. The purpose of this article is to present a Global Nurse Agenda for Climate Justice to spark dialog, provide direction, and to promote nursing action for just-relations and responsibility for planetary health. Grounding ourselves within the Mi'kmaw concept of Etuaptmumk (two-eyed seeing), we suggest that climate justice is both call and response, moving nurses from silence to Ksaltultinej (love as action). We review the movement for climate justice in nursing, weaving between our own stories, our relations with Mi'kmaw ways of knowing, and the stories of the movement, with considerations for the (w)holistic perspectives foundational to nursing's metaparadigm of person, environment, and health. We provide a background to the work of the Global Nurse Agenda for Climate Justice steering committee including their role at the 26th United Nations Climate Change Conference in Glasgow, 2021, and share our own stories of action to frame this agenda. We accept our Responsibility for the challenges of climate justice with humility and invite others to join us.

Associations between climate change-related factors and sexual health: A scoping review

There is growing attention to the ways in which climate change may affect sexual health, yet key knowledge gaps remain across global contexts and climate issues. In response, we conducted a scoping review to examine the literature on associations between climate change and sexual health. We searched five databases (May 2021, September 2022). We reviewed 3,183 non-duplicate records for inclusion; n = 83 articles met inclusion criteria. Of these articles, n = 30 focused on HIV and other STIs, n = 52 focused on sexual and gender-based violence (GBV), and n = 1 focused on comprehensive sexuality education. Thematic analysis revealed that hurricanes, drought, temperature variation, flooding, and storms may influence HIV outcomes among people with HIV by constraining access to antiretroviral treatment and worsening mental health. Climate change was associated with HIV/STI testing barriers and worsened economic conditions that elevated HIV exposure (e.g. transactional sex). Findings varied regarding associations between GBV with storms and drought, yet most studies examining flooding, extreme temperatures, and bushfires reported positive associations with GBV. Future climate change research can examine understudied sexual health domains and a range of climate-related issues (e.g. heat waves, deforestation) for their relevance to sexual health. Climate-resilient sexual health approaches can integrate extreme weather events into programming.

From biodiversity to nature deficiency in human health and disease

Nature (biodiversity) loss is the loss or decline of the state of nature taking place in the wider environment. We present a novel concept, nature deficiency, referring to nature loss in the human body influencing health. Humans are connected with the natural environment and its microbes and biogenic chemicals through eating (drinking), breathing, and touching. The mental and sociocultural links to the environment are also strong. With medical and ecological research and guidelines, the diagnosis, prevention, and treatment of nature deficiency may become part of the clinical practice. Nature prescription is likely to find plausible forms in patient care and inspire preventive actions at the society level. Health professionals are in a key position to integrate public health promotion and environmental care.

Barriers and facilitators to sustainable operating theatres: a systematic review using the Theoretical Domains Framework

BACKGROUND

The health sector contributes significantly to the climate crisis. Operating theatres (OTs) in particular are a major contributor of greenhouse gas emissions and waste, and while there are several evidence-based guidelines to reduce this impact, these are often not followed. The authors systematically reviewed the literature to identify barriers and facilitators of sustainable behaviour in OTs, categorising these using the Theoretical Domains Framework (TDF).

MATERIALS AND METHODS

Medline, Embase, PsychInfo, and Global Health databases were searched for articles published between January 2000 and June 2023, using the concepts: barriers and facilitators, sustainability, and surgery. Two reviewers screened abstracts from identified studies, evaluated quality, and extracted data. Identified determinants were mapped to TDF domains and further themes as required. The results were reported in line with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) and AMSTAR (A MeaSurement Tool to Assess Systematic Reviews) guidelines.

RESULTS

Twenty-one studies were selected for analysis and assessment (17 surveys and four interview studies) comprising 8286 participants, including surgeons, nurses, and anaesthetists. Eighteen themes across 10 TDF domains were identified. The most common barriers to adoption of green behaviours in OTs were in domains of: 'knowledge' ( N =18), for example knowledge of sustainable practices; 'environmental context and resources' ( N =16) for example personnel shortage and workload and inadequate recycling facilities; 'social influences' ( N =9) for example lack of leadership/organisational mandate or support; 'beliefs about consequences' ( N =9) for example concerns regarding safety. Intention was the most common facilitator, with 11 studies citing it.

CONCLUSIONS

Despite intentions to adopt sustainable practices in OTs, this review identified several barriers to doing so. Interventions should focus on mitigating these, especially by improving staff's knowledge of sustainability practices and working within the environmental context and time pressures. Furthermore, institutional change programmes and policies are needed to prioritise sustainability at the hospital and trust level. Additional qualitative work should also be conducted using behavioural frameworks, to more comprehensively investigate barriers and determinants to decarbonise OTs.

Cost Savings and Waste Reduction Through Redispensing Unused Oral Anticancer Drugs: The ROAD Study

Importance

New strategies targeting waste are required to improve financial and ecologic sustainability of expensive therapies, such as oral anticancer drugs, that frequently remain unused by patients. Redispensing unused oral anticancer drugs seems to be a promising strategy when drug quality is guaranteed.

Objectives

To determine the waste reduction and net cost savings attained by redispensing oral anticancer drugs that go unused by patients compared with the standard practice of disposal.

Design, Settings, and Participants

The ROAD study was a prospective single-group intervention conducted in the outpatient pharmacies of 4 hospitals in the Netherlands from February 1, 2021, to February 1, 2023, with 12-month follow-up of each patient. Patients with cancer and who had a prescription for an oral anticancer drug that could be stored at room temperature were included. Of 2426 eligible patients, 602 did not consent and 601 did not respond. Data analyses were performed from August 25, 2022, to April 19, 2023.

Intervention

Participants received oral anticancer drugs for use at home in special packaging (ie, sealed packaging with time-temperature indicator), to be returned to the pharmacy should these remain unused. The pharmacy ensured quality of returned drugs based on authenticity, appearance, remaining shelf life and adequate storage temperature. Drugs fulfilling quality requirements were redispensed to other patients.

Main Outcome and Measure

Total waste reduction and mean net annual cost savings per patient compared with the standard practice of disposal. Optimization of cost savings was explored by introducing variations in the quality assurance procedure and patient population. All analyses used the average exchange rate for 2021 €1 = US $1.18.

Results

Of 1223 patients with cancer who consented, 1071 participated (median [IQR] age, 70 [62-75] years; 622 [58.1%] were male). In all, 171 patients (16.0%; 95% CI, 13.8%-18.3%) returned 335 unused oral anticancer drug packages. Of the returned drugs, 228 packages were redispensed, which reduced waste by 68.1% (95% CI, 67.7%-68.5%) compared with the standard practice (disposal). Redispensing unused oral anticancer drugs comprised 2.4% (95% CI, 2.2%-2.5%) of total drug costs, providing mean net annual cost savings of US $680 (95% CI, $524-$837) up to $1591 (95% CI, $1226-$2002) per participant.

Conclusions and Relevance

The findings of this multicenter intervention study indicate that redispensing unused oral anticancer drugs is associated with waste reduction and cost savings, which in turn may improve the affordability and sustainability of cancer treatment.

Trial Registration

World Health Organization International Clinical Trials Registry Platform Identifier: NL9208.

The development of ecological civilization in China based on the economic-social-natural complex system

China is making great efforts to build an ecological civilization. To reveal the effectiveness and spatial characteristics of the ecological civilization development in China, we constructed an Ecological Civilization Evaluation Index (ECI) based on the economic-social-natural complex system. We evaluated the development level of the ecological civilization in China from 2004 to 2020 and discussed the coupling and coordination relationship between subsystems. We found that the ecological civilization of China has achieved remarkable results. The relationship among the three subsystems has been improved to some extent, but the high-quality development of the economic system still requires effort. The development level of the ecological civilization in China presents spatial heterogeneity. From east to west, 30 provinces can be classified into four different types of development. On the whole, the development of China's ecological civilization has provided experiences for the world.

The role of mental health nurses in planetary health

This article will critically explore the concept of planetary health and locate the role and identity of the mental health nurse (MHN) within it. Like humans, our planet thrives in optimum conditions, finding the delicate balance between health and ill-health. Human activity is now negatively impacting the homeostasis of the planet and this imbalance creates external stressors that adversely impact upon human physical and mental health at the cellular level. The value and understanding of this intrinsic relationship between human health and the planet is in danger of being lost within a society that views itself as being separate and superior to nature. The Period of Enlightenment witnessed some human groups viewing the natural world and its resources as something to exploit. White colonialism and industrialization destroyed the innate symbiotic relationship between humans and the planet beyond recognition and in particular, overlooking the essential therapeutic role nature and the land facilitated within the well-being of individuals and communities. This prolonged loss of respect for the natural world continues to breed human disconnection on a global scale. The healing properties of nature have effectively been abandoned within healthcare planning and infrastructure, which continue to be driven principally by the medical model. Under the theory of holism, mental health nursing values the restorative capabilities of connection and belonging, employing skills to support the healing of suffering, trauma and distress, through relationships and education. This suggests MHNs are well situated to provide the advocacy the planet requires, through the active promotion of connecting communities to the natural world around them, both healing the other.

Financial influence on global risks of zoonotic emerging and re-emerging diseases: an integrative analysis

BACKGROUND

Emerging and re-emerging infectious diseases (EIDs), such as Ebola virus disease and highly pathogenic influenza, are serious threats to human health and wellbeing worldwide. The financial sector has an important, yet often ignored, influence as owners and investors in industries that are associated with anthropogenic land-use changes in ecosystems linked to increased EIDs risks. We aimed to analyse financial influence associated with EIDs risks that are affected by anthropogenic land-use changes. We also aimed to provide empirical assessments of such influence to help guide engagements by governments, private organisations, and non-governmental organisations with the financial sector to advance a planetary health agenda.

METHODS

For this integrative analysis, we identified regions in the world where there was evidence of a connection between EIDs and anthropogenic land-use changes between Nov 9, 1999, and Oct 25, 2021, through a targeted literature review of academic literature and grey literature to identify evidence of drivers of anthropogenic land-use change and their association with commodity production in these regions. We only included publications in English that showed a connection between deforestation and the production of one or more commodities. Publications merely describing spatial or temporal land-use change dynamics (eg, a reduction of forest or an increase of palm-oil plantations) were excluded. As we were assessing financial influence on corporate activities through ownership specifically, we focused our analysis on publicly listed companies. Equity data and data about ownership structure were extracted from Orbis, a company information database. We assessed financial influence by identifying financial entities with the largest equity ownership, descriptively mapping transboundary connections between investors and publicly listed companies.

FINDINGS

227 public and private companies operating in five economic sectors (ie, production of palm oil, pulp and wood products, cocoa, soybeans, and beef) between Dec 15, 2020, and March 8, 2021, were identified. Of these 227, 99 (44%) were publicly listed companies, with 2310 unique shareholders. These publicly listed companies operated in six geographical regions, resulting in nine case-study regions. 54 (55%) companies with complete geographical information were included in the countries network. Four financial entities (ie, Dimensional, Vanguard, BlackRock, and Norway's sovereign wealth fund) each had ownership in 39 companies or more in three of the case-study regions (ie, north America, east Asia, and Europe). Four large US-based asset managers (ie, Vanguard, BlackRock, T Rowe Price, and State Street) were the largest owners of publicly listed companies in terms of total equity size, with ownership amounts for these four entities ranging from US$8 billion to $21 billion. The specific patterns of cross-national ownership depended on the region of interest; for example, financial influence on EIDs risks that was associated with commodity production in southeast and east Asia came from not only global asset managers but also Malaysian, Chinese, Japanese, and Korean financial entities. India, Brazil, the USA, Mexico, and Argentina were the countries towards which investments were most directed.

INTERPRETATION

Although commodity supply chains and financial markets are highly globalised, a small number of investors and countries could be viewed as disproportionally influential in sectors that increase EIDs risks. Such financial influence could be used to develop and implement effective policies to reduce ecological degradation and mitigate EIDs risks and their effects on population health.

FUNDING

Formas and Networks of Financial Rupture-how cascading changes in the climate and ecosystems could impact on the financial sector.

Sustainable diets among youth: Validity and reliability of a questionnaire assessing knowledge, attitudes, practices, and willingness to change

BACKGROUND

In light of the global commitment to promoting sustainable dietary choices and the pivotal role of young adults in the adoption of these choices, it is paramount to understand their perspectives of healthy and sustainable diets. The present study aimed to investigate the validity and reliability of a questionnaire examining the knowledge, attitudes, practices, and willingness to change regarding sustainable diets among young adults in the United Arab Emirates (UAE).

METHODS

Male and female students attending University of Sharjah, UAE (n = 436), completed an online questionnaire consisting of four sections: knowledge, attitudes, practices, and willingness to change with regard to sustainable diets. Of the participants, 106 completed the questionnaire a second time, 1 month later. Factor analysis (FA) (both exploratory and confirmatory), Cronbach-α, interitem correlations, and intra class correlation (ICC) coefficients were used in the data analysis.

RESULTS

Exploratory FA revealed four factors corresponding to the components of the questionnaire. Results of the confirmatory FA indicated a good fit: the χ2 df ratio was < 5 (2.3), root mean squared error of approximation was < 0.08 (0.048) and the comparative fit index was above 0.9 (0.901). Cronbach α and interitem correlations were: knowledge: 0.57 and 0.21; attitude: 0.70 and 0.28; practices: 0.76 and 0.39; willingness to change: 0.69 and 0.27. The ICC coefficients, assessing the reliability of the questionnaire, ranged between 0.48 and 0.92 for the various items.

CONCLUSIONS

The developed questionnaire is a valid and reliable tool that could be used to identify the gaps and opportunities for the development of evidence-based interventions aiming to enhance the uptake of sustainable diets among young adults.

A systems science leverage point analysis of climate change advocacy

Failure of governments across the world to address climate change has fuelled social movements focused on climate-related policy and action. Research analysing these movements has focused mainly on the types of strategies employed including blockades and occupations, marches and petitions, divestment, boycotts and litigation as well as how groups are framing climate change as a problem. What has been largely missed are the ways these groups are framing the change they want to see, that is their demands to governments. Not all demands and actions have the same potential to create the changes needed to mitigate climate change. Used in public health and health promotion, the systems science Intervention Level Framework (ILF) is a tool that can help analyse to what extent different demands have the leverage to create change in a system. We use the ILF to analyse 131 demands from 35 different climate-related advocacy groups in Australia. Results show demands are more focused on lower system leverage points, such as stopping particular projects, rather than on more impactful leverage points, such as the governance structures that determine climate-related policy and decision-making mechanisms. Further, the results highlight the lack of attention on public health related topics of transport and food systems. This paper shows how a systems science framework used in health promotion, the ILF, could enable climate advocacy groups to more effectively target demands to achieve more impactful outcomes from governments, corporations and the public.

The mental health impacts of human-ecosystem-animal relationships: A systematic scoping review of Eco-, Planetary, and One Health approaches

The threats to human and animal health, biodiversity conservation, and our living planet's future are ever-present and increasingly more severe due to climate change and environmental degradation. There is an emerging discourse exploring the mental health dimensions contained within these changes. To better understand and respond to these impacts requires novel and creative methodological approaches built on conceptual frameworks that integrate perspectives from the social and natural sciences. Three of the most influential interdisciplinary frameworks at the human-animal-ecosystem interface include: One Health, EcoHealth, and Planetary Health. These frameworks report mental health as an integral component within overall health-related outcomes. However, a comprehensive synthesis of the state of the literature that examines how mental health is explored within these approaches does not currently exist. A systematic scoping review was therefore conducted to obtain clear understandings of patterns, gaps, and broad themes, and to highlight future research needs and considerations. Standardized PRISMA guidelines, including explicitly defined inclusion/exclusion criteria and dual screening/extractions, were used. 13 papers were included: seven using the One Health Framework, with Planetary and EcoHealth each represented by three. Trends observed include a predominate focus on companion animals as interventions, "sense of place" used as a component of mental well-being, and non-physical health-related measurements of animal well-being as an outcome within One Health research. The lack in retrieved studies also highlight the dearth in literature on mental health as a pillar of these three well established frameworks. Compiling what is known in the evidence-base as a launching point for scientific engagement, this review describes guidance for investigators on how to conduct mental health research within these framework parameters so that future studies can elucidate mechanisms underpinning the intersections between the biosphere and human mental-health and data-driven interventions and policy recommendations that simultaneously address mental health and global change can be proposed and enacted.

What Are Healthy Societies? A Thematic Analysis of Relevant Conceptual Frameworks

BACKGROUND

While support for the idea of fostering healthy societies is longstanding, there is a gap in the literature on what they are, how to beget them, and how experience might inform future efforts. This paper explores developments since Alma Ata (1978) to understand how a range of related concepts and fields inform approaches to healthy societies and to develop a model to help conceptualize future research and policy initiatives.

METHODS

Drawing on 68 purposively selected documents, including political declarations, commission and agency reports, peer-reviewed papers and guidance notes, we undertook qualitative thematic analysis. Three independent researchers compiled and categorised themes describing the domains of a potential healthy societies approach.

RESULTS

The literature provides numerous frameworks. Some of these frameworks promote alternative endpoints to development, eschewing short-term economic growth in favour of health, equity, well-being and sustainability. They also identify values, such as gender equality, collaboration, human rights and empowerment that provide the pathways to, or underpin, such endpoints. We categorize the literature into four "components": people; places; products; and planet. People refers to social positions, interactions and networks creating well-being. Places are physical environments-built and natural-and the interests and policies shaping them. Products are commodities and commercial practices impacting population health. Planet places human health in the context of the 'Anthropocene.' These components interact in complex ways across global, regional, country and community levels as outlined in our heuristic.

CONCLUSION

The literature offers little critical reflection on why greater progress has not been made, or on the need to organise and resist the prevailing systems which perpetuate ill-health.

How to Build Healthy Societies: A Thematic Analysis of Relevant Conceptual Frameworks

BACKGROUND

As the Sustainable Development Goals deadline of 2030 draws near, greater attention is being given to health beyond the health sector, in other words, to the creation of healthy societies. However, action and reform in this area has not kept pace, in part due to a focus on narrower interventions and the lack of upstream action on health inequity. With an aim to guide action and political engagement for reform, we conducted a thematic analysis of concepts seeking to arrive at healthy societies.

METHODS

This paper drew on a qualitative thematic analysis of a purposive sample of 68 documents including political declarations, reports, peer reviewed literature and guidance published since 1974. Three independent reviewers extracted data to identify, discuss and critique public policy levers and 'enablers' of healthy societies, the "how."

RESULTS

The first lever concerned regulatory and fiscal measures. The second was intersectoral action. The final lever a shift in the global consensus around what signifies societal transformation and outcomes. The three enablers covered political leadership and accountability, popular mobilization and the generation and use of knowledge.

CONCLUSION

Documents focused largely on technical rather than political solutions. Even as the importance of political leadership was recognized, analysis of power was limited. Rights-based approaches were generally neglected as was assessing what worked or did not work to pull the levers or invest in the enablers. Frameworks typically failed to acknowledge or challenge prevailing ideologies, and did not seek to identify ways to hold or governments or corporations accountable for failures. Finally, ideas and approaches seem to recur again over the decades, without adding further nuance or analysis. This suggests a need for more upstream, critical and radical approaches to achieve healthy societies.

Aligning Environmental Sustainability, Health Outcomes, and Affordability in Diet Quality: A Systematic Review

Improving diet quality while simultaneously maintaining planetary health is of critical interest globally. Despite the shared motivation, advancement remains slow, and the research community continues to operate in silos, focusing on certain pairings (diet-climate), or with a discipline-specific lens of a sustainable diet, rather than examining their totality. This review aimed to summarize the literature on adherence to a priori defined dietary patterns in consideration of diet quality, metabolic risk factors for noncommunicable diseases (NCDs), environmental impacts, and affordability. A methodology using PRISMA guidelines was followed, and searches were performed in 7 databases as of October 2022. The Appraisal tool for Cross-Sectional Studies (AXIS) and the National Institutes of Health (NIH) quality assessment tool for observational cohort studies were employed for quality appraisal. The evidence was narratively synthesized according to the characteristics of the diet quality metrics. The review includes 24 studies published between 2017-2023. Thirteen distinct diet quality scores were identified, with those measuring adherence to national dietary guidelines the most reported. Thirteen distinct environmental impact indicators were identified, with greenhouse gas emissions (n=23) reported most. All studies reported on body mass index, and 7 studies assessed the cost of adherence. Our results are consistent with previous findings that healthier diets can reduce environmental impacts; however, incongruities between population and planetary health can occur. Hence, the "sustainability" of dietary patterns is dependent on the choice of indicators selected. Further, healthy, lower impact diets can increase financial cost, but may also provide a protective role against the risk of obesity. Given the Global Syndemic, strategies to reduce obesity prevalence should emphasize the win-win opportunities for population and planetary health through dietary change. Research should identify diets that address multiple environmental concerns to curtail burdens potentially transferring, and harmonize this with sociocultural and equity dimensions. This review was registered at PROSPERO as CRD42021238055.

Nature-based biopsychosocial resilience: An integrative theoretical framework for research on nature and health

Nature-based solutions including urban forests and wetlands can help communities cope better with climate change and other environmental stressors by enhancing social-ecological resilience. Natural ecosystems, settings, elements and affordances can also help individuals become more personally resilient to a variety of stressors, although the mechanisms underpinning individual-level nature-based resilience, and their relations to social-ecological resilience, are not well articulated. We propose 'nature-based biopsychosocial resilience theory' (NBRT) to address these gaps. Our framework begins by suggesting that individual-level resilience can refer to both: a) a person's set of adaptive resources; and b) the processes by which these resources are deployed. Drawing on existing nature-health perspectives, we argue that nature contact can support individuals build and maintain biological, psychological, and social (i.e. biopsychosocial) resilience-related resources. Together with nature-based social-ecological resilience, these biopsychosocial resilience resources can: i) reduce the risk of various stressors (preventive resilience); ii) enhance adaptive reactions to stressful circumstances (response resilience), and/or iii) facilitate more rapid and/or complete recovery from stress (recovery resilience). Reference to these three resilience processes supports integration across more familiar pathways involving harm reduction, capacity building, and restoration. Evidence in support of the theory, potential interventions to promote nature-based biopsychosocial resilience, and issues that require further consideration are discussed.

Planetary Health: Preparing Nursing Students for the Future

BACKGROUND

Climate change around the globe is impacting human and planetary health at unprecedented rates. Nurses are well positioned to act as climate leaders, given their critical role globally.

PROBLEM

Current and future nurses must work to mitigate climate-related health effects. It is necessary that a planetary health approach is integrated into nursing education.

APPROACH

Curricular modifications, using the Planetary Health Education Framework, are presented, which will promote awareness and understanding of climate health among future nurses. The framework is grounded in equity, which is well suited to nursing education, and can be readily adapted into current nursing curricula.

OUTCOMES

Recommendations for nursing education are presented within the 5 domains of the framework.

CONCLUSIONS

Future nurses are called on to be exemplary planetary health communicators, educators, advocates, and leaders. The Planetary Health Education Framework promotes nursing leadership in practice and in advocating for a climate-resistant future.

[Urban green and blue spaces in times of climate change]

Both climate mitigation and adaptation are urgently needed as complementary strategies for sustainably reducing and managing urban health risks posed by climate change. The positive effects of urban green and blue spaces on physical and mental health are well-known since decades. However, there is intensive competition around the use of the urban space. Reflecting the European Aalborg Charta (1994), German building laws require development plans to be sustainable in this demanding context with human health being a concern of central importance. Reality, however, remains challenging. Although there are numerous best practice examples, research on the impact of urban green and blue spaces on human health and well-being is still required. Furthermore, all relevant policy fields need to develop awareness of the importance of green and blue spaces for quality of life and health, so that the issue of health is taken into consideration adequately as well as in a socially sensitive manner in urban decision processes.

Exposure to urban nanoparticles at low PM[Formula: see text] concentrations as a source of oxidative stress and inflammation

Exposures to fine particulate matter (PM[Formula: see text]) have been associated with health impacts, but the understanding of the PM[Formula: see text] concentration-response (PM[Formula: see text]-CR) relationships, especially at low PM[Formula: see text], remains incomplete. Here, we present novel data using a methodology to mimic lung exposure to ambient air (2[Formula: see text] 60 [Formula: see text]g m[Formula: see text]), with minimized sampling artifacts for nanoparticles. A reference model (Air Liquid Interface cultures of human bronchial epithelial cells, BEAS-2B) was used for aerosol exposure. Non-linearities observed in PM[Formula: see text]-CR curves are interpreted as a result of the interplay between the aerosol total oxidative potential (OP[Formula: see text]) and its distribution across particle size (d[Formula: see text]). A d[Formula: see text]-dependent condensation sink (CS) is assessed together with the distribution with d[Formula: see text] of reactive species . Urban ambient aerosol high in OP[Formula: see text], as indicated by the DTT assay, with (possibly copper-containing) nanoparticles, shows higher pro-inflammatory and oxidative responses, this occurring at lower PM[Formula: see text] concentrations (< 5 [Formula: see text]g m[Formula: see text]). Among the implications of this work, there are recommendations for global efforts to go toward the refinement of actual air quality standards with metrics considering the distribution of OP[Formula: see text] with d[Formula: see text] also at relatively low PM[Formula: see text].

Measuring Nurses' Knowledge and Awareness of Climate Change and Climate-Associated Diseases: Protocol for a Systematic Review of Existing Instruments

BACKGROUND

Climate change is a health emergency. Each year, it is estimated to cost more than 230 million years of life expectancy, with 4-9 million premature deaths associated with air pollution, and 9 million excess deaths due to non-optimal temperatures, representing 7% more temperature-related deaths since 2015 and 66% more since 2000.

OBJECTIVE

Identify and evaluate the reliability, fidelity, and validity of instruments measuring nurses' knowledge and awareness of climate change and climate-associated diseases.

METHODS

A systematic literature review will retrieve and assess studies examining instruments measuring nurses' knowledge and awareness of climate change and climate-associated diseases. Using predefined search terms for nurses, climate change, literacy and scales or tools, we will search for published articles recorded in the following electronic databases, with no language or date restrictions, from their inception until 31 October 2023: Medline Ovid SP (from 1946), PubMed (NOT Medline[sb], from 1996), Embase.com (from 1947), CINAHL Ebesco (from 1937), the Cochrane Library Wiley (from 1992), Web of Science Core Collection (from 1900), the Trip Database (from 1997), JBI OVID SP (from 1998), and the GreenFILE EBSCO. We will also hand-search relevant articles' bibliographies and search for unpublished studies using Google Scholar, ProQuest Dissertations and Theses Global, and DART-EUrope.eu. This will be completed by exploring the gray literature in OpenGrey and the Grey Literature Report, from inception until 31 October 2023, in collaboration with a librarian. Twelve bibliographic databases will be searched for publications up to 31 October 2023. The papers selected will be assessed for their quality.

RESULTS

The electronic database searches were completed in May 2023. Retrieved articles are being screened, and the study will be completed by October 2023. After removing duplicates, our search strategy has retrieved 3449 references.

CONCLUSIONS

This systematic review will provide specific knowledge about instruments to measure nurses' knowledge, awareness, motivation, attitudes, behaviors, beliefs, skills, and competencies regarding climate change and climate-associated diseases.

The effect of an app-based dietary intervention on diet-related greenhouse gas emissions - results from a randomized controlled trial

BACKGROUND

Dietary change towards a diet low in greenhouse gas emissions (GHGEs) can reduce climate impact and improve individual-level health. However, there is a lack of understanding if diet interventions can achieve low-GHGE diets.

METHODS

A randomized controlled trial was conducted to assess the effects of an app-based intervention. The intervention was designed to improve dietary intake of people with Type 2 diabetes, and was delivered via an app over 12 weeks, with each week covering one diet-related topic. Dietary intake was assessed at baseline and 3-month follow up by a 95-item food frequency questionnaire and linked to GHGE values. A total of n = 93 participants (n = 46 and n = 47 for the intervention and control group, respectively) were included in the analysis. Changes to GHGEs within and between the groups were analysed with inferential statistics.

RESULTS

The majority (60%) of participants were male, with a mean age of 63.2 years and body mass index of 30 kg/m2. At baseline, diet-related GHGEs were 4.8 and 4.9 kg CO2-eq/day in the intervention and control group, respectively. At 3-month follow up the corresponding GHGEs were 4.7 and 4.9 kg CO2-eq/day. We found no statistically significant changes to diet-related GHGEs within or between groups, or within food categories, from baseline to 3-month follow up.

CONCLUSION

No evidence was found for the effectiveness of the app-based intervention to generate changes to diet-related GHGEs in a population of people with Type 2 diabetes. However, future interventions that target reducing meat consumption specifically may have the potential to result in a reduction of individual-level diet-related GHGEs.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03784612. Registered 24 December 2018. www.

CLINICALTRIALS

gov/ct2/show/NCT03784612 .

Perceptions, attitudes, awareness and perspectives towards sustainability practices and climate change among nurses: a systematic review protocol

INTRODUCTION

Climate change has been described as the most significant threat to humanity and human health to have emerged this century. It is widely accepted that contemporary human activities are the major causes of climate change. It is also acknowledged that damaging human activities could be amenable to change through proactive environmental behaviours. Healthcare professionals have the potential to promote climate advocacy and mitigation through collective effort and individual actions. However, research suggests that nurses may not be aware of their potential to effect positive action. This review will synthesise evidence regarding nurses' perceptions, attitudes, awareness and perspectives towards sustainable nursing practices and climate change.

METHODS AND ANALYSIS

The Joanna Briggs Institute (JBI) methodology for mixed-methods systematic reviews will be applied to this proposed systematic review. It will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. CINAHL, PsycINFO, SCOPUS and PubMed databases will be searched. Data appraisal will be completed using the JBI and Mixed Methods Assessment Tool critical appraisal tool. Data synthesis and integration will follow the JBI convergent integrated approach.

ETHICS AND DISSEMINATION

In compliance with university ethics requirements for secondary research and postgraduate researchers, ethical approval will be sought from the Coventry University Ethics Committee, UK. Dissemination of findings will be achieved through peer-review publications, conference presentations and seminars with local, national and international audiences.