The Challenge for Public Health Stephen Palmer Cardiff University and Public Health Wales

Health ProtectionHealth Improvement Health Services Improvement Prevents epidemics and the spread of disease Promotes and encourages healthy behaviours Assure the quality and accessibility of health services Protects against environmental hazards Prevents injuries Responds to disasters and assists communities in recovery What is Public health? USA UK

Standardised ratios for congenital anomalies Before opening 0.87 ( ) After opening 1.21 ( ) Ratio 1.39 ( ) All 22 sites in Wales opening from < 2 km v km

Community Engagement over Congenital Birth Defects near the Nantygwyddon landfill, Community Engagement over Congenital Birth Defects near the Nantygwyddon landfill, Max Wallis + June Bacon Trehafod Heritage Park Rhondda, March 2005 Wales Network

Physical Environment ommunity Engagement over Congenital Birth Defects near the Nantygwyddon landfill Community Engagement over Congenital Birth Defects near the Nantygwyddon landfill Max Wallis + June Bacon Trehafod Heritage Park Rhondda, March 2005 Public campaigning crucial for getting con. mals on the local public health agenda Official guardians of public health failed to follow up the epidemiology findings Epidemiology ‘false negative’ provided excuse for inaction Community activists have identified and drawn attention to continuing gastroschisis cases Precautionary principle required official action

Characteristic Adjusted** Odds ratios (95% CI) Stress sum All: 5 Major stressful life events:- Serious relationship diff / legal financial problems / victim of violence / injury illness / death (0.4,2.8) 2+4.9(1.2,19.4) Same address Yes1.0 No4.9(1.7,13.9) Cigarettes smoke per day in first trimester > (1.3,11.4) > 10 cigarettes in one day 4.3(1.0,18.0) Woman binge drinker ≥ 6 units in one sitting/day in first trimester No1.0 Yes1.6(0.64.2) Body Mass index Underweight3.4(0.6,20.8) Normal1.0 Overweight0.8(0.3,2.5) Obese0.1(0.02,0.6) Typical number of portions of fruit or vegetables eaten per week in first trimester ≤ 6 portions a week (0.1,1.5) (0.1,0.9) (0.03,0.8) Duration in weeks of folic acid supplementation during first trimester < 6 out of first 12 weeks1.0 ≥ 6 out of first 12 weeks0.3(0.1,0.8) National case control study of Gastroschisis

“Our aim is to create sustainable communities - places where people want to live and work, now and in the future … we aim to improve the lives of people in deprived communities and socially excluded groups who experience poor quality of life, including poor local environmental quality and poor access to services” Sustainable Communities – a new paradigm for Public Health? “No community, here or overseas, wants to be faced with problems which lead to them becoming caught in a cycle of degradation and poverty, with a consequent lack of community pride in their area, poor environmental quality and health, high crime and unemployment levels, and multiple inequalities ”

“I want a Wales fit for generations to come … What motivates me is doing my very best to ensure a brighter, sustainable future for [my grandchildren and their grandchildren] and every other child growing up in Wales today … [Therefore], top of the list … of our priorities which will continue to improve the quality of life for people today and in the future … is sustainability” First Minister, 8 February 2008 Sustainable Communities – a new paradigm for Public Health?

Social This and Economic Future Natural Generations What Sustainable Communities means

Option appraisal Advice Action Outcomes Evaluation Problem identification Risk assessment Expertise, Knowledge, Research, Training Modelling Standards Surveillance Audit Tracking Alerts Lessons Evidence into Action Cycle

“Reliable information on the environment, population health and their linkages is essential to optimally prioritize, develop and evaluate policies and actions in order to reduce hazardous environmental exposures and their effects” (WHO Euro)

Public Health Wales Observatory Mortality from coronary heart disease

PISA 2009 results

Wales Electronic Cohort of Children (Lyons et al) 122,827 children born in Wales between 1995 – 2001 Risk of NOT achieving Key Stage 1 (age 7) by social deprivation decile adjusted for gender, free school meals, parity, maternal age, smoking, breastfeeding, gestation at birth

Wales Electronic Cohort of Children (Lyons et al) 122,827 children born in Wales between 1995 – 2001 Risk of NOT achieving Key Stage 1 by gestation at birth adjusted for gender, free school meals, parity, maternal age, smoking, breastfeeding, social deprivation measure.

Relation between model predicted change in mental health scores, social cohesion and enumeration district income deprivation (% low income households < £ per annum)

Housing Regeneration and Health Study Collaboration with Carmarthenshire County Council (Lyons et al) Bringing 9,256 social homes to modern quality standards - £207M internal works: kitchen units, bathroom suites, downstairs toilets, central heating, rewiring windows and doors: double-glazed, locks thermal insulation: walls and loft gardens and estate package: fencing, security lights, paths in good condition Using SAIL to evaluate and quantify the health benefits of housing improvement to 2016 NIHR funded

CHALICE Evaluating changes in exposure to alcohol outlet density using multiple GIS approaches on alcohol consumption and measures of alcohol related harm (Fone et al) Welsh Health Survey: 75,000 participants (2005-9) Hospital admissions ED attendances Alcohol related violent crime NIHR funded

REAT: An observational tool to assist with the assessment of urban residential environments. Dunstan et al, Journal of Environmental Psychology, 25 (2005) Physical incivilitiesTerritorial functioningDefensible space Natural environment Other

Objectively measured neighbourhood quality and self-reported health Dunstan, Fone, Glickman, Palmer 31,000 residents 777 post codes Tertile 2 Adjusted individual and area deprivation Tertile 3 Adjusted individual and area deprivation VariableOR95% CIOR95% CI REAT1.37(1.24, 1.51)1.36(1.22, 1.49) Physical incivilities1.34(1.20, 1.49)1.30(1.16, 1.46) Territorial functioning 1.33(1.20, 1.47)1.47(1.33, 1.61) Defensible space1.18(1.07, 1.30)1.18(1.08, 1.30) Natural elements1.01(0.91, 1.12)1.03(0.93, 1.14) Miscellaneous0.97(0.89, 1.07)1.00(0.91, 1.11)

The Challenge for Environmental Public health Accepting the paradigm of Sustainable Communities Interaction of environments Priority to generational effects Developing robust evidence Measuring what matters Creating healthy places homes and neighbourhoods