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1 Introduction

Many features characterise a healthy urban environment in today’s world. A healthy city is self-evidently one where physical hazards are kept to a minimum but also where healthy and sustainable lifestyles are promoted and inhabitants are stimulated to become involved with the places they live. These and other criteria can only be fulfilled using an integrated approach that connects health goals with the protection of natural resources and ecosystems while stimulating multisectoral and multidisciplinary collaboration .

In this chapter, we identify the urban environment as a key battleground in what is arguably the twenty-first century’s greatest public health challenge—the need for humanity to reflect in all its decisions and actions and the interconnection between humans and the natural processes and systems on which they rely for health, wellbeing and, ultimately, survival. The term ‘ecological public health’ is increasingly used to encapsulate both this challenge and the required response. Recent international developments, notably the United Nations 2030 Agenda for Sustainable Development, offer a favourable policy platform and an unprecedented opportunity to pursue meaningful change in a coordinated way. While applauding the emergence of this improved policy context, no one should underestimate the complexity of a task that demands, among other things, a rethink of how we live, move and consume in our urban centres. Our purpose here is to briefly describe the urban environment and its challenges but, more especially, to promote the utility and importance of conceptual models as tools with which to think and guide the dialogue among stakeholders to shape the urban policies for a healthier, more sustainable and more equal world.

2 Ecological Public Health

The recognition that health, wellbeing, disease and social patterning in these outcomes are emergent products of a complex interaction of factors operating at the level of society with characteristics specific to the individual has been hugely influential across the field of public health for over 40 years.

What were typically described as ‘ecological’ or ‘socioecological’ perspectives in public health gained prominence in the 1970s, stimulated in large part by concerns over the burgeoning and unsustainable costs of healthcare. Through their writings and schematic representations, proponents of a ‘new public health’ (see, e.g. Lalonde 1974; Evans and Stoddart 1990; Dahlgren and Whitehead 1991) elegantly expressed complexity in the determinants of health in a helpful and policy-relevant way. Among the benefits was a renewed policy focus on the wider structural determinants of health and of health-relevant behaviours and an implicit challenge to public health to abandon intra- and interdisciplinary silos and reach out to other constituencies of policy and practice. Moreover, socioecological perspectives helped drive research which created a much richer understanding of the role of physical environment in health and wellbeing. Going beyond narrow compartmentalised and hazard-focused environmental concerns, the environment came, increasingly, to be recognised as contributory in a wide variety of high-profile health and health-related outcomes . These included non-communicable diseases, mental health and wellbeing, health inequalities and, later, the obesity epidemic. Spurred in part by socioecological perspectives but also moral indignation over health inequity, scientific research has gradually revealed the true importance of the environment for health and wellbeing in the modern era. An important finding is, for example, that high-quality environments , especially pleasant green and natural spaces, can promote better, more equal health (see, e.g. Hartig et al. 2014). There is also growing acceptance of a psychosocial dimension in the relationship between people and the physical context in which they live which contributes to mental and physical wellbeing (Gee and Payne-Sturges 2004).

Despite describing significant complexity in the determinants of health, wellbeing and equity, much of the rhetoric and many of the schematics initially proposed to support the ‘ecological’ perspectives of the late twentieth century (Evans and Stoddart 1990; Dahlgren and Whitehead 1991) now appear deficient in one very significant respect. Specifically, they seem to disregard or downplay the dynamic interaction and interdependence between human beings and the natural environment and the fact that human health and wellbeing is a product of this interdependence (Coutts et al. 2014; Morris et al. 2015). Fortunately, as the twenty-first century has progressed, references to the ecological perspectives and the concept of ‘ecological public health’ permeating the literature reflect not only human social complexity in the determinants of health but also the interconnectedness of humans with their natural environment. ‘Ecological public health’, as it is now construed, recognises the absurdity of any model that regards human beings, their social and economic activities and their health and wellbeing as somehow separate and distinct from natural systems. Indeed, there is a growing acceptance, given the damage now being wrought on planetary processes and systems by human activity that it may well be impossible to deliver health and wellbeing, healthcare or equity in any of these areas in the medium to long term without thinking in a much more focused way about the environment (Rayner and Lang 2012; Morris et al. 2015; Morris and Saunders 2017).

For most of the last 10,000 years, the Earth’s systems and processes have been essentially stable, presenting conditions favourable to human health and development, and, despite gross inequity in their distribution, abundant resources have also been available to support human life. However, over the space of less than two centuries, humans have moved to become the principal drivers of change at planetary level. The grave implications for humanity are cogently expressed in the concept of ‘planetary boundaries’ . Refining earlier work (Rockström et al. 2009), Steffen and colleagues proposed nine specific limits or ‘planetary boundaries’ relating to the biophysical subsystems and processes which ensure the Earth’s habitability for humans (Steffen et al. 2015). Yet, already by 2015, four of these limits—those relating to the addition of phosphorus and nitrogen to crops and ecosystems, biodiversity, land use changes (including deforestation) and, arguably most alarmingly, climate change—had all been breached and, with them, what the authors termed a ‘safe operating space for humanity’ . The risks are amplified by the likelihood that the systems, which are in various ways connected, may now respond unpredictably and in a non-linear fashion. Citing this and the outcomes of similar research, the World Health Organisation is just one among a host of commentators now emphasising that a ‘business as usual’ approach is no longer a viable option to secure health and wellbeing and to improve equity (see, e.g. WHO 2017, Morris and Saunders, 2017; Rayner and Lang 2012). In an insightful commentary, Rayner and Lang (2012) have argued that ecological public health is the twenty-first century’s unavoidable task. While different terminology may be used across the public health literature to encapsulate the threat, there is broad agreement concerning the need, henceforth, to build population health on ecological principles and around the huge scale of the challenge. The fact that wherever we live in the world, our health will in future be profoundly influenced by the changes to planetary processes and systems, which we as individuals influence confers a distinctly global dimension to everyday public health practice in the twenty-first century. Nonetheless, an important frontline in the battle is likely to remain the towns, cities and rural locations in which we move, consume and live out our daily lives. Working in partnership, policymakers, public agencies, the private sector and indeed citizens themselves carry responsibility for identifying and delivering the policies and actions necessary for a healthy, equitable and sustainable future. Here, we argue that relatively simple conceptual models of health and its determinants already exist which have capacity to guide these policies and actions at national and subnational level.

3 Policy Platform

Healthy and sustainable urban development has been included as a key objective in various recent international agreements such as UN 2030 Agenda for Sustainable Development, the New UN Urban Agenda and the EU Urban Agenda.

The UN 2030 Agenda for Sustainable Development with its Sustainable Development Goals (SDGs) might be regarded as the political embodiment, not only of the quest for global sustainability and equity but also modern ecological thought in public health. The SDGs and in particular SDG11 ‘Make cities inclusive, safe, resilient and sustainable’, can be seen as an overarching framework for policy to improve the environment and health in cities (UN 2015). SDG11, however, is not the only SDG with an urban dimension. The 17 SDGs and 169 related indicators aim to eradicate poverty and inequality, create inclusive economic growth, preserve the planet and improve population health. Many have an environmental and health dimension that, as well as addressing climate change, holds potential for significant public health improvements particularly in cities (WHO 2017; Carmichael et al. 2017; Pruss Ustun et al. 2016).

Drawing on ideas and developments from the Dutch context, Agenda Stad (2016), and championed by the Netherlands during its European Union presidency, the 2016 EU Urban Agenda European Commission (2015) also recognises both the challenge and opportunity present in the urban context. It aims to strengthen the urban dimension of European policies, to create better regulations and promote knowledge exchange. The EU Agenda focuses on sectors relevant to environment, health and equity, with pilot partnerships established to address four of these themes—air quality, housing, inclusion of migrants and refugees and urban poverty—over the next 2–3 years (Urban Agenda for the EU 2015). Importantly, it promotes vertical and horizontal coordination of policies, impact assessment, and knowledge exchange. A major objective is to contribute to SDG11.

A further component of the international policy platform is represented by the New Urban Agenda (NUA) . This was adopted by the UN Habitat III Conference in 2016 and emphasises the key role of cities in the pursuit of sustainable development. The NUA reiterates the commitment to interlink social, environmental and economic principles and to rethink how we build, manage and live in the urban context. Of particular relevance to the theme of this chapter and its emphasis on tools to think with at a local level, the NUA recognises that national governments are leaders in the definition and implementation of inclusive and effective urban policies. The contribution of subnational and local government, civil society and other relevant stakeholders is no less important in order to achieve satisfactory outcomes (United Nations 2016).

4 Why Is the Urban Environment So Central to Ecological Public Health?

The process of urbanisation is seemingly unremitting and most of the World’s population already lives in cities. In Europe, for example, from 1950 to 2011, the percentage of the population living in urban areas increased from 51% to 73%, and this has been predicted to reach 83% in 2050 (EEA 2015). However, the importance of urbanisation for health wellbeing and the future of humanity is founded on much more than numbers and scale. How cities are planned and managed can profoundly affect citizen health and wellbeing, both directly and indirectly.

Self-evidently, cities can provide access to services—such as energy, water, housing, green spaces, transport and climate protection. They can also be the source of multiple economic and social benefits, which enhance the mental and physical wellbeing of those who live there.

In contrast, badly planned, poorly managed and ill-regulated cities expose citizens to threats from air pollution, noise, waste and vehicle-related hazards. Cities can produce social isolation and shape the life choices of their citizens in ways which can be damaging to their health and wellbeing—perhaps promoting or sustaining unhealthy and sedentary lifestyles implicated in a global epidemic of non-communicable diseases and obesity (Carmichael et al. 2017; Staatsen et al. 2017).

Health inequalities by many measures are all too evident between and within countries, and it is often the urban context that throws up the most striking examples of poor health and health inequity. Differences in the quality, availability and maintenance of urban infrastructures and services (such as housing, water and sanitation, the work environment, transport systems, green infrastructure and food shops) frequently manifest in health inequity in many countries. Some of the poorest life circumstances are endured by the urban poor (FRESH 2015a; Carmichael et al. 2017).

For these and other reasons, the urban context must remain a key focus for public health activity (WHO 2017). However, it is the recognition that cities are also a key battleground in the pursuit of global sustainability that catapults them to the forefront of the modern public health challenge.

Put simply, through influencing and managing change to how people live, move and consume, cities can offer among the best health-promoting and sustainable opportunities . For example, a shift from motorised transport to active transport (providing enough safe biking and walking routes as well as public transport) provides health and wellbeing benefits. Promoting active transport and clean fuel use will lead to a reduction of greenhouse gas emissions.

Scientific evidence is growing on the important role played by urban green and blue spaces in delivering considerable health and wellbeing benefits, promoting biodiversity as well as protecting from the impacts of climate change (heavy rainfall, temperature increases). Urban gardening can contribute to more sustainable and healthy food consumption. Improvement of housing quality and use of renewable energy sources may reduce fuel poverty and respiratory complaints, as well as mitigate climate change.

Urban planning decisions play an important role in protecting and promoting the health and wellbeing of its residents, as well as enhancing urban ecosystems. Figure 33.1 offers an interesting typology for modern cities. It describes for example features of a ‘clean’ city, ‘green’ city or a ‘social city’. In a ‘clean’ city, the focus is on the protection against classic environmental risk and the provision of basic services. In a ‘green ‘or ‘physically active’ city, the focus is on the health promoting features of a city. This model has been developed by a consortium of Dutch architects and health professionals and is used in dialogues with stakeholders to help determine ambitions and focus (Platform Healthy Design 2013).

Fig. 33.1
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Ten typologies of cities (Source: Platform Healthy Design 2013)

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It is abundantly clear that the urban environment represents an extremely dynamic context for public health activity. Those in positions of responsibility in cities must anticipate and respond in a timely fashion to an evolving situation. Demographic changes are creating a rapidly ageing population, many with pre-existing illness and enhanced vulnerability. A changing climate may fundamentally alter the physical context of urban life in ways that are important for health, wellbeing and equity. Together, these and other developments significantly challenge policymakers and demand a detailed understanding of the forces that act to shape the physical and social environment in cities and how citizens interface with them. Conceptual models have potential to enable policy and other decision-makers to navigate in complex and changing circumstances to identify effective policies.

5 Conceptual Models in Public Health

Driven by advances in science and technology, but also by wider societal changes over two centuries, there has been a clear evolution in ideas about the determinants of health and disease. Shifts in what are sometimes called ‘health paradigms’ have delineated different eras in public health and enabled useful configuring frameworks within which to pursue better, more equitable population health (Susser and Susser 1996).

In 1974, a Canadian government white paper, ‘A New Perspective on the Health of Canadians’, was launched in response to concerns over potentially bankrupting healthcare costs in that country (Lalonde 1974). In seeking a more inclusive and preventative approach to tackling the burden of disease, the white paper argued that any health problem could be traced to one or more of four elements, termed ‘health fields’. These were lifestyle, human biology, environment (physical and social) and healthcare organisation. This more inclusive and preventive perspective made explicit the many different constituencies of policy and practice that influence health outcomes. Despite its specific Canadian focus, the white paper had international impact, driving the socioecological perspectives that would come to dominate the public health rhetoric in Western society. However, the white paper might also be seen as important in nurturing interest in conceptual modelling in public health. Specifically, the ‘health fields’ offered a tool for the analysis of health problems and allowed the significance and interaction of various influences to be explored in a policy-relevant way. The capacity to generate ‘maps of the health territory’ for different issues was emphasised although the white paper was not intended to present actual evidence. Rather, its aim was to present an approach which could elucidate causal pathways (Lalonde 1974; Morris et al. 2006).

In hindsight, it seems counterintuitive that the Canadian white paper did not go as far as to present a schematic or visual representation of the four health fields, yet what was described was, by any interpretation, a ‘conceptual model of health’. It was to become a creating precedent for much that would follow. Emerging somewhat later, the iconic ‘Social Model of Health’ (Dahlgren and Whitehead 1991) (see Fig. 33.2) and Socioecological Model of Health (Evans and Stoddart 1990) (see Fig. 33.3) added depth and breadth to the socioecological perspectives of Lalonde and further developed the idea of conceptual models as tools for analysis in public health policy and action. Citing the white paper as direct precedent, in 1990, Evans and Stoddart presented their ‘Socioecological Model of Health’ as a framework for the assembly of evidence ‘in a way that would make its implications more apparent’ and added rather insightfully that ‘there is much more to policy than evidence’ (Morris et al. 2006).

Fig. 33.2
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The Social Model of Health . Source: Dahlgren and Whitehead (1991)

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Fig. 33.3
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The Socioecological Model of Health . Source: Evans and Stoddart (1990)

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Although it has its own distinct origins and trajectory , the development of conceptual modelling in environmental health policy, right up until the present day, is unquestionably influenced by these earlier attempts to model the determinants of health.

6 Conceptual Models in Environmental Health

For much of the post-World War II period in public health, the operational challenge around environment was invariably presented as one of identifying, monitoring and controlling a limited set of toxic or infectious agents in environmental carriers such as food, air, water and soil (Morris and Saunders 2017). Expressed conceptually, the challenge was about how policy and action might impact beneficially on a linear causal pathway leading from hazardous environmental state(s) to group or individual environmental exposure, and on to a (usually negative) health effect. This might be seen as a ‘State Exposure-Effect’ sequence. From a policy perspective, this representation has proved useful but is also limiting, not least in its failure to represent the (frequently anthropogenic) driving forces that, in turn, create the pressures which act upon and modify the environmental state: a ‘Driver-Pressure-State’ sequence .

6.1 The DPSEEA Model and Its Derivatives

Although their initial purpose was to create an organising framework for the development and use of environmental health indicators, the importance for policy of integrating ‘Driver-Pressure-State’ with ‘State-Exposure-Effect’ sequences to create a single full chain approach was first articulated by Kjellstrom and Corvalan (1995) and Briggs et al. (1996). These co-workers subsequently presented a simplified version of their Drivers-Pressures-State-Exposure-Effect-Actions model as a configuring framework for decision-making in environmental health (Corvalán et al. 2000).

The DPSEEA model offered, for the first time, a much more integrated and policy-relevant conceptualisation of the relationship among human activity, the physical environment and health. Unsurprisingly perhaps, the DPSEEA model has formed the basis for development of a family of conceptual models now finding application in the field of environmental health (Fig. 33.4).

Fig. 33.4
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The DPSEEA model . Source: Adapted and simplified from Corvalán et al. (2000)

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6.2 The ‘Modified DPSEEA Model’

In 2006, Morris and colleagues developed a modified version of the DPSEEA model (Morris et al. 2006); see Fig. 33.5. The modified or mDPSEEA model was developed as the configuring framework for a new policy approach to environment and health in Scotland. The policy ‘Good Places Better Health’ (Scottish Government 2008, 2012) was intended to embody socioecological perspectives, taking environmental health activity beyond narrow, compartmentalised and hazard-focused roots, exploring the contribution of environment, in combination with other societal influences and characteristics of the individual in promoting and perpetuating health.

Fig. 33.5
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The modified DPSEEA model . Source: Morris et al. (2006)

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In this way, it was hoped to identify and address more effectively the environmental contribution to complex health challenges such as obesity, diminished mental health and wellbeing and inequalities in health by a variety of measures. Moreover, the policy sought to reflect a much richer interpretation of the role of environment by recognising the potential of high-quality environments to nurture better, more equal health and wellbeing. The mDPSEEA model differs from the original DPSEEA model (Corvalán et al. 2000) by incorporating a ‘contextual bubble’ indicating that whether an environmental state (positive or negative) translates into an exposure for an individual is, in every case, critically influenced by a set of interacting contextual factors. These might include demographic, socioeconomic and behavioural influences. In addition, whether an exposure translates into a negative or positive health effect for the individual is influenced by a further set of contextual influences, such as age, gender, pre-existing health status or even the presence of other environmental stressors.

From a policy perspective, it is important to note that existing and proposed interventions (actions) can be directed towards the DPSEEA chain itself and towards elements of the context. A key finding of the prototype phase of Good Places Better Health was that conceptual models like mDPSEEA, when applied to specific issues, can be a means to configure different categories of evidence, a framework for data collection, a vehicle for identifying gaps in knowledge (generating a research agenda) and a tool for policy analysis. Furthermore, the process and product of populating the model for a specific issue or problem is highly effective in engaging the multiple and diverse stakeholders whose inputs or omissions may be critical influence on health outcomes . Perhaps the most useful overarching outcome was the affirmation of the observation by McIntosh et al. (2007) that conceptual models can be useful ‘tools to think with’.

This was especially evident through the use of the mDPSEEA model as an issue framing tool in facilitated stakeholder workshops in Scotland.

6.3 The ‘Ecosystem-Enriched’ (eDPSEEA) Model

Cities can usefully be viewed as urban metabolisms and complex systems of flow management and the result of resource allocation, distribution and deployment through time. Conceptual models have a role in explaining the synergies which occur in cities between the environment, human activity and human health, making more explicit the connections among society, the economy, the environment and health and wellbeing and highlighting the importance of biodiversity in both human and planetary health (Carmichael et al. 2017). Reis et al. (2015) further developed the mDPSEEA model to produce the ecosystem (e)-enriched model, or ‘eDPSEEA model’. In Fig. 33.6, we present an expanded version of the eDPSEEA model as originally conceived. This reveals its component elements in greater detail. As with mDPSEEA, the model is conceived as a tool to think with in a policy context, but critically one which recognises that human impacts on global processes and systems are now damaging health, wellbeing and equality within and between communities. The model allows the environmental threat to health and wellbeing to be modelled on the vastly extended temporal and spatial scale necessary if mankind is to build health and wellbeing henceforth on ecological principles. Expressed in another way, it is a tool with which to operationalise the concept of ecological public health described in the introduction of this chapter.

Fig. 33.6
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The ecosystem-enriched or eDPSEEA model. Source: Reis et al. (2015)

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The ‘ecosystem-enriched DPSEEA model ’ continues to capture the dimensions of the environment and health relationship represented by the mDPSEEA model where driving forces create pressures which change health-relevant characteristics of environmental state near, or ‘proximal’ to, a community. However, eDPSEEA also represents another pathway from driving forces to the health and wellbeing of that community. This so-called ‘distal’ pathway from driving forces to health and wellbeing effects is concerned with damage to global systems, processes and the consequent changes to environmental state in places remote from the community whose activities generate the harm (Morris et al. 2015). Phenomena such as environmentally driven mass migration or food insecurity mean that any sense of remoteness from the impacts we cause is likely to prove illusory. The eDPSEEA model draws on the insights of the Millennium Ecosystem Assessment (2005) to link ecosystem damage to human health and wellbeing through considering its impact on ecosystem services. Ecosystem services are the benefits human beings receive from the natural environment and are expressed in terms of provisioning services (food, fuel, fibre, etc.), regulating services (waste treatment, climate regulation, etc.) and cultural services (the non-material benefits such as tourism or inspiration) all of which are underpinned by supporting services such as soil processes, photosynthesis, etc. When ecosystem services are interupted, human wellbeing can be undermined in five distinct ways. These are the (a) denial of material goods (so-called material minima), (b) disruption of social relationships, (c) diminished security, (d) reduced freedom of choice and (e) direct damage to mental and physical health (Millennium Ecosystem Assessment 2005).

While it is entirely distinct in its origins from the DPSEEA family of models, another useful inclusion within a toolkit of models to aid policy and practice in the urban context is the Egan model (see Fig. 33.7). A product of the ‘Egan Review’ of 2004, it encapsulates the notion that sustainable communities should address the diverse needs of current and future residents and their children by offering a choice: communities should make effective use of natural resources, enhance and embrace the environment, strengthen social cohesion and increase the economic outlook of communities and the residents.

Fig. 33.7
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The Egan model (Source: Egan 2004)

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6.4 The Ecosystem-Enriched, Behaviourally Enhanced DPSEEA or ‘INHERIT Model ’

At the time of writing, the INHERIT model (Staatsen et al. 2017) (see Fig. 33.8) represents the most recent addition in the development of DPSEEA models. Ostensibly quite different in appearance, the model shares key common elements with the eDPSEEA model (most notably in representing two pathways from multiple interacting drivers to health and wellbeing outcomes).Footnote 1 The INHERIT model serves to support the development of the Horizon 2020-funded INHERIT project (www.inherit.eu/) which seeks to identify effective intersectoral policies and interventions that promote sustainable and healthy lifestyles and behaviour in the areas of living, moving and consuming.

Fig. 33.8
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The behaviourally enhanced, ecosystem-enriched DPSEEA model , or INHERIT model (Staatsen et al. 2017)

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The INHERIT model emphasises that behaviour should be taken into account when developing and choosing policies and interventions to improve people’s health and environmental sustainability and reduce inequalities and health inequities and thereby achieve a ‘triple win’. Accordingly, the first significant difference from other members of the ‘DPSEEA family’ is the integration of the Behavioural Change Wheel (BCW). The BCW (Michie et al. 2011) is a theory and evidence-based tool with which interventions and policies can be selected/developed that change behaviour. The core of the wheel consists of three behavioural components: COM-B, capability (to be physically or psychologically capable of performing certain behaviour), opportunity (all factors outside individual that can make a certain behaviour possible or not) and motivation (brain processes that direct behaviour, such as conscious decision-making, but also habits). These components interact and together influence behaviour. Different intervention functions (e.g. restriction or education) can influence (one or more) different behavioural components. These interventions can be enabled by different types of policy (such as legislation). Another essential difference with previous versions of the DPSEEA model is that, throughout the model, magnifying glasses are used to represent behavioural hotspots: parts of the causal process that are heavily influenced by human behaviour and thus important parts towards which actions may be directed.

A further feature of the INHERIT model lies in its attention to the issue of inequalities. These are represented throughout the model to emphasise that driving forces, pressures and the resultant environmental state will all differ significantly according to location, creating and sustaining inequalities between individuals and different communities. Expressed in another way, driving forces exist in many combinations and do not create the same pressures for everyone: some populations are affected more than others. Using the example of the food environment in disadvantaged neighbourhood, often a proliferation of fast food outlets varies significantly creating more obesogenic environments for disadvantaged populations. Behaviour is one of the elements in the equation leading to these differences, as people may have different motivations and capabilities that lead them to perform different (health-related) behaviours and interact differently with their environments.

As in the eDPSEEA model (see Fig. 33.6), the INHERIT model shows both a proximal pathway and a distal pathway, the latter demonstrating a Driver-Pressure-Ecosystem Services-Health impacts sequence. This takes account of the fact that multiple interacting and predominantly anthropogenic driving forces which exist today are creating pressures which are impacting Western European populations in the here and now but also future and distant populations. Most obviously, the impacts of global warming, with extreme weather events damaging crops, reducing food supplies, seriously affect health and wellbeing in other parts of the world.

7 Applying Conceptual Models to Urban Environmental Health Challenges

To illustrate the effectiveness of conceptual models in an urban context and to identify those actions that will address the environment, health and equity challenges in cities in an effective way, we describe the use of the ecosystem-enriched model in a pilot exercise.

In 2015 a workshop was organised with experts from the network of the European Environmental Agency (EEA) . The primary purpose of the workshop was to provide participants with an insight into how the conceptual models might be ‘populated’ and used for a dialogue with policymakers, scientists, city planners and citizens. The topics selected for further discussion were healthy transport, healthy housing and climate. Using discussion methods like ‘knowledge-café’ and ‘brainwriting’, the conceptual framework was discussed, relevant indicators and future challenges and barriers were identified, as well as options for actions.

While presented here as a proof of concept rather than a comprehensive analysis, Fig. 33.9 illustrates the application of the eDPSEEA model in the case of urban transport. It shows how identical drivers such as (lack of) investments in public transport and infrastructure, urban and transport planning, cultural norms and individual preference (the demand for convenience, speed and comfort) influence health through direct pathways (proximal, near in space and time) and more indirectly through land use and ecosystem impacts (distal route).

Fig. 33.9
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Addressing the effects and actions of transport through DPSEEA models. Source: FRESH (2015b) and FRESH Transport leaflet (FRESH 2015c). Modelling approach derived from Reis et al. (2015)

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Drivers put pressure on the proximal urban environment (state) by influencing land use, the availability of (green) space, walking or cycling networks and traffic density. As a result, individuals may be subjected to air pollution, more noise and higher temperatures or have (negative or positive) experiences in relation to exercising or leisure, depending on the availability of cycling networks and parks. The way these changes to the proximal environment in cities affect individual or community health and wellbeing is however dependent on interacting contextual factors such as their stage of life and socioeconomic circumstances. Air pollutants from motorised transport may also have an effect on climate change. Although, for European cities, these changes may appear distal in that they appear to be happening elsewhere or seem to be a concern for future generations, they are of course real and ‘proximal’ threats to the people in the places affected. Moreover, in a world connected economically, socially and environmentally, Europeans are never isolated from the environmental, social and health changes occurring now and later elsewhere in the world (Staatsen et al. 2017; FRESH Consortium 2014a, b; Carmichael et al. 2017).

The eDPSEEA conceptual framework, and especially the process of populating the model for an issue in multiple stakeholder groups, helps frame the issue and identify (often hidden) associations, as well as co-benefits and unintended side consequences. Many policies in the field of neighbourhood planning, housing and transport offer co-benefits. For example, policies that promote cycling benefit health and wellbeing in a variety of ways while potentially reducing greenhouse gas emissions. However, other policies intended to produce benefits to environment, health and wellbeing may have unintended consequences which are damaging to health. For example, measures which have encouraged the widespread use of diesel cars with the intention of reducing CO2 emissions have added to background concentrations of particulates which are damaging to respiratory and cardiovascular health.

The eDPSEEA conceptual framework also offers a structured approach to identify useful indicators for evaluating and monitoring the impact of policies on the environment, health and wellbeing. The correct indicators , presented in a relational way, are central to understanding problems and measuring progress in addressing proximal and distal impacts (Fig. 33.10). Thus, models like eDPSEEA can offer a useful configuring framework around which to build an information system.

Fig. 33.10
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Indicators for evaluating and monitoring impacts of transport at an (inter)national level. Source: FRESH (2015b) and FRESH Climate change leaflet (FRESH Consortium 2014a, b)

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In many cities, there are experiments involving the promotion of active mobility, electric driving, free public transport or banning private cars from city centres. Information is not always available for these experiments, and there is a need to improve the evaluation and exchange of such information. For example, the evidence base for stimulating people to shift from car use to active transport is based mostly on cross-sectional studies. There is a lack of long-term measurements addressing the proximal and distal impacts of a modal shift (Staatsen et al. 2017). The development and application of a common set of indicators to evaluate this type of intervention (such as those which have been developed in FRESH and are being developed in INHERIT), would be extremely useful.

An analysis of Sustainable Urban Mobility Plans (SUMP) shows a wide variation in the way climate change and equity are addressed in cities (Arsenio et al. 2016 in Staatsen et al. 2017). The elaborated INHERIT model holds promise as vehicle for raising awareness of equity issues in transport and critically the role of human behaviour in influencing outcomes.

Also of direct relevance to the urban context, the eDPSEEA model has also been applied to the domain of housing (see Fig. 33.11). Housing construction, maintenance, the location and occupation of houses and access to services have an impact on the health and wellbeing of the occupants (Braubach et al. 2011). Important drivers in the area of healthy housing include population density, age profile, economy/income (increasing socioeconomic inequalities), lifestyles, spatial planning and policies regarding housing materials and construction standards, consumer products and energy saving. There is a variety of indoor chemicals (VOCs, CO, NO2, tobacco smoke, asbestos), microbiological (mould, dust) and physical agents in houses and building blocks associated with a range of health impacts (i.e. respiratory and cardiovascular diseases). The populated model also shows that policies to secure energy efficiency might reduce ventilation rates and by extension GHG emissions . However, these very same policies might profoundly reduce indoor air quality to the detriment of occupant health and wellbeing. The potential for conflict between housing policies motivated by energy conservation or other building-related concerns and environmental health should be considered at an early stage of planning in order to minimise negative health impacts. Large social inequalities in housing between and within EU member states are also evident (FRESH 2015a; Staatsen et al. 2017).

Fig. 33.11
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Addressing the effects and actions of housing through the DPSEEA model. Source: FRESH Housing leaflet (FRESH Consortium 2014b)

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Effective design and governance of healthy and sustainable cities relies on the awareness of these complex interactions, feedback loops and the trade-offs involved. This can be achieved, by securing more stakeholder involvement, to inform cross-cutting analysis and synthesis and to reflect on implications.

The integrated conceptual models described above imply that urban and transport planners and architects need to work together with environmental scientists, public health specialists, local communities and those from many other disciplines to make sense of the complexities of the urban metabolism and inform policymakers about actions to regulate human activities, encourage changes in behaviour and promote equity (Carmichael et al. 2017, p. 51; Staatsen et al. 2017).

8 Discussion and Conclusions

In this chapter, we have presented a number of different conceptual models. The very existence of so many models implies that many researchers and policymakers find them useful in understanding the complex interacting factors that shape our world and our health. However, those creating the models we have illustrated would readily subscribe to the maxim that ‘all models are wrong but some are useful’ (Box 1979).

The Dahlgren and Whitehead and Evans and Stoddart models (see Figs. 33.2 and 33.3) each offer representations of the relationship between societal and individual factors in creating and destroying health and wellbeing. We highlighted a limitation common to each of these models in that both fail to fully represent the interdependence of human health and that of natural systems and processes. However, it would be remiss not to recognise the seminal influence of both models in challenging siloed thinking and work practices in public health. In particular, the models were and remain very valuable tools for analysing the socially complex ‘proximal’ context, which many policymakers and practitioners encounter in the here and now.

Coming a little later, and following something of a societal awakening around the threat to the natural systems on which we rely, the Egan Model is particularly effective in illustrating the many dimensions of a sustainable community and has clear application as a tool for community engagement in pursuing that aspiration.

We have presented above the evolution of the ‘DPSEEA family of models’ (DPSEEA, mDPSEEA, eDPSEEA and INHERIT) each of which places the relationship between physical environment and health at its core. It would be a mistake to assume however that each subsequent iteration of the model represents a progression towards a more sophisticated and, by implication, ‘better’ understanding. It is true that with each iterations add further dimensions and increased scope are added. Yet it is important to note that each form of the model was developed to serve a particular purpose and earlier versions are not necessarily superseded or rendered obsolete by those developed later. All are useful inclusions within a toolkit of conceptual models that can be deployed by policymakers and practitioners when seeking to engage with others and to produce beneficial change.

The product and process of populating models for different issues has proved useful for engaging multiple stakeholders: providing an understanding of the contribution of others and communicating messages to a wider constituency. Models have great potential as configuring frameworks for information systems and for highlighting in gaps whether in knowledge, information or policy. At their simplest, conceptual models are ‘tools to think with’ in an increasingly complex world and can be applied at differing scales from the international to the very local.

We are attracted by the idea that a conceptual model is analogous to a camera. The user initially has a number of cameras from which to choose. Having chosen, he or she may then adjust the focus, zoom in or out (scale), make a film (time) and think about different perspectives (Schram-Bijkerk et al. 2016). A user can focus on health (and use, e.g. Dahlgren and Whitehead’s model (1991)) and sustainability (the Egan model, life cycle analysis, etc.) or opt for an integrated approach and use the eDPSEEA or INHERIT model described above.

In this chapter, our focus has been on the application of conceptual models in the cities of the twenty-first century. Our justification is simple. Wherever we live in the world, our health and wellbeing, our pursuit of equity and our future as individuals and as a species are inextricably bound up with the natural environment. This is both the message and the challenge of ecological public health. It is a global challenge which demands insightful public health thinking on a markedly extended temporal and spatial scale. However, arguably the most important frontline in the battle to achieve the triple win of health and wellbeing, equity and sustainability remains, as it has so often been throughout history the urban environment. Cities are the theatres where society can make the greatest progress in meeting the ecological public health challenge and where risks that attend failure will be felt most acutely. Impacts on city level depend on and interact with processes and impacts on neighbourhood, district and national scale, which is difficult to capture in one-dimensional models. The aspect of time is also important to consider. We need integrated models like the eDPSEEA and INHERIT model that help us selecting those actions that are healthy and sustainable in the future, as well as inclusive.

If we are to begin to identify and gain support for the actions which simultaneously protect both ecosystems and human health and wellbeing, in ways which are socially inclusive, sustainable and equitable, globally and across multiple generations, we need tools to work with.