Environmental health promotion : development, implementation and evaluation

Environmental health deals with those aspects of human health and disease that are
determined by factors in the environment. It does not only include direct effects of
harmful substances but also more indirect consequences of the physical and
psychosocial environment on health and wellbeing. It also comprises the assessment
and control of environmental factors which can potentially affect health. The “National
Environment and Health Action Plans” (NEHAPs), which have been developed
throughout Europe since the middle of the 1990s, are a novel attempt for an integrated
environment and health policy. The Swiss NEHAP, which is implemented since 1998,
was among the first to be developed in an industrialized country. It focuses on the three
topic “Nature and Wellbeing”, “Mobility and Wellbeing” and “Housing and
Wellbeing”. There are a number of open issues in relation to the development,
implementation and evaluation of such environmental health promotion programs,
which were addressed in this thesis. Housing quality is often named as a key area in environmental health. However, the
scientific basis for the development of appropriate promotion strategies on housing
quality and wellbeing is incomplete. In the first part of this thesis, data from a study on
perceived housing quality and wellbeing, which was carried out in the north-western
Region of Switzerland, is presented. The study showed that a higher satisfaction with
environmental housing quality and with the apartment was associated with an improved
wellbeing of movers. The positive association with environmental indicators was
persistent in participants who had moved for other than environmental reasons.
However, it could not be entirely clarified which single factors in the residential
environment were most influential. Both environmental indicators “perceived air
quality” and “location of the building” seemed to reflect a group of different
determinants. It can be concluded that an integrated approach should be applied in
projects aiming at the improvement of the housing quality, taking the respective
situation and views of the ones affected into account. But the lack of scientific evidence is not the only challenge in the development of
environmental health promotion programs. A general discussion of strengths and
weaknesses of the development and implementation process of the Swiss NEHAP
showed that the strengths of the Swiss NEHAP lie in the formulation of specific targets
in selected areas, its approach as a environmental health promotion program, and its
comprehensive evaluation. Environmental health promotion is always an intersectorial
activity. Therefore, all relevant actors, ideally within as well as outside the
administration, should be involved into the development of such programs to ensure
their collaboration. It was shown that a good inter-administrational involvement was
achieved in the development process of the Swiss NEHAP. Weaknesses in most
NEHAPs are the lack of involvement of the general public and of the economic sector,
and the absence of an implementation strategy along with adequate financing. The
greatest challenge in the implementation of this in principal valuable framework will be
to ensure the link between health and environment on a structural level beyond an
intersectorial development phase to build a real and long-term stable alliance. Evaluation should be an inherent part of every health promotion program. The
comprehensive evaluation of the Swiss NEHAP consists on the one hand of the
continuous analysis of the implementation of the program (process evaluation). On the
other hand, indicators were defined based on impact models to assess aim-related
outcomes and a selected number of more distal impacts (outcome and impact
evaluation). The baseline assessment of these indicators in 1999/2000 underlined the
need for action in the three topics Mobility, Housing, and Nature. As a major
consequence of feedback from the process evaluation, an implementation program for
the Swiss NEHAP was developed in 2001. During the development of this
implementation program, it became apparent that it would not be possible to reach the
aims formulated for the three topics until 2007 on a national level with the resources at
hand. Consequently, the objectives were redefined focusing on three pilot regions. It has
also been recognized that a long term perspective will be necessary to achieve truly
intersectorial collaboration and structural changes. Meanwhile, the World Health Organization (WHO) started with the development of a
set of environmental health indicators for international application. As a contribution to the ongoing discussion on the different approaches in relation to environmental health
indicators and their application, the WHO indicator set was compared with the Swiss
evaluation indicators. Additionally, the suitability of an international indicator set for
the evaluation of national programs was discussed. The set of environmental health
indicators (EHIs) proposed by the WHO serves a structured description of the
underlying cause-effect chains. The set is useful for monitoring and international
comparison of the general environment and health situation, thus supporting priority
setting. However, a number of methodological and technical difficulties need to be
addressed, particularly in relation to health impact assessment. Indicators for the
evaluation of NEHAPs were derived from previously formulated policy targets while
EHIs, in contrast, should lead to priority setting and policy formulation. Additionally,
the relevance of internationally developed indicators will vary in the national context
and they do not allow to evaluate the policy implementation process. Therefore, the
suitability of EHIs for the evaluation of national environmental health promotion
programs is limited. Challenges for the future lie in the development of a set of environmental health
indicators, which allows international comparisons and at the same time responds to
national priorities, and in the elaboration of health indicators in the framework of
sustainable development monitoring in industrialized countries such as Switzerland.