Integrating Social Determinants in Decision-Making Processes for Health: Insights from Conceptual Frameworks-the 3-D Commission.

The inclusion of social determinants of health offers a more comprehensive lens to fully appreciate and effectively address health. However, decision-makers across sectors still struggle to appropriately recognise and act upon these determinants, as illustrated by the ongoing COVID-19 pandemic. Consequently, improving the health of populations remains challenging. This paper seeks to draw insights from the literature to better understand decision-making processes affecting health and the potential to integrate data on social determinants. We summarised commonly cited conceptual approaches across all stages of the policy process, from agenda-setting to evaluation. Nine conceptual approaches were identified, including two frameworks, two models and five theories. From across the selected literature, it became clear that the context, the actors and the type of the health issue are critical variables in decision-making for health, a process that by nature is a dynamic and adaptable one. The majority of these conceptual approaches implicitly suggest a possible role for data on social determinants of health in decision-making. We suggest two main avenues to make the link more explicit: the use of data in giving health problems the appropriate visibility and credibility they require and the use of social determinants of health as a broader framing to more effectively attract the attention of a diverse group of decision-makers with the power to allocate resources. Social determinants of health present opportunities for decision-making, which can target modifiable factors influencing health-i.e. interventions to improve or reduce risks to population health. Future work is needed to build on this review and propose an improved, people-centred and evidence-informed decision-making tool that strongly and explicitly integrates data on social determinants of health.

Improving Decision-Making for Population Health in Nonhealth Sectors in Urban Environments: the Example of the Transportation Sector in Three Megacities-the 3-D Commission.

Noncommunicable diseases (NCDs) represent a significant global public health burden. As more countries experience both epidemiologic transition and increasing urbanization, it is clear that we need approaches to mitigate the growing burden of NCDs. Large and growing urban environments play an important role in shaping risk factors that influence NCDs, pointing to the ineluctable need to engage sectors beyond the health sector in these settings if we are to improve health. By way of one example, the transportation sector plays a critical role in building and sustaining health outcomes in urban environments in general and in megacities in particular. We conducted a qualitative comparative case study design. We compared Bus Rapid Transit (BRT) policies in 3 megacities-Lagos (Africa), Bogotá (South America), and Beijing (Asia). We examined the extent to which data on the social determinants of health, equity considerations, and multisectoral approaches were incorporated into local politics and the decision-making processes surrounding BRT. We found that all three megacities paid inadequate attention to health in their agenda-setting, despite having considerable healthy transportation policies in principle. BRT system policies have the opportunity to improve lifestyle choices for NCDs through a focus on safe, affordable, and effective forms of transportation. There are opportunities to improve decision-making for health by involving more available data for health, building on existing infrastructures, building stronger political leadership and commitments, and establishing formal frameworks to improve multisectoral collaborations within megacities. Future research will benefit from addressing the political and bureaucratic processes of using health data when designing public transportation services, the political and social obstacles involved, and the cross-national lessons that can be learned from other megacities.

A Systems Understanding Underpins Actions at the Climate and Health Nexus.

Multiple sectors-health and non-health-can determine the health and well-being of people and the condition of the socio-ecological environment on which it depends. At the climate and human health nexus, a systems-based understanding of climate change and health should inform all stages of the policy process from problem conceptualization to design, implementation, and evaluation. Such an understanding should guide countries, their partners, and donors to incorporate health in strategic climate actions based on how health is affected by, and plays a role in, the dynamic interactions across economic, environmental, and societal domains. A systems-based approach to sustainable development has been widely promoted but operationalizing it for project level and policy development and implementation has not been well articulated. Such an approach is especially valuable for informing how to address climate change and health together through policy actions which can achieve multiple, mutually reinforcing goals. This commentary article describes strategic steps including the complementary use of health impact assessment, quantification of health impacts, and linking climate and health actions to national and global policy processes to apply a systems-based approach for developing climate mitigation and adaptation actions with human health benefits.

Transdisciplinary Research Priorities for Human and Planetary Health in the Context of the 2030 Agenda for Sustainable Development.

Human health and wellbeing and the health of the biosphere are inextricably linked. The state of Earth's life-support systems, including freshwater, oceans, land, biodiversity, atmosphere, and climate, affect human health. At the same time, human activities are adversely affecting natural systems. This review paper is the outcome of an interdisciplinary workshop under the auspices of the Future Earth Health Knowledge Action Network (Health KAN). It outlines a research agenda to address cross-cutting knowledge gaps to further understanding and management of the health risks of these global environmental changes through an expert consultation and review process. The research agenda has four main themes: (1) risk identification and management (including related to water, hygiene, sanitation, and waste management); food production and consumption; oceans; and extreme weather events and climate change. (2) Strengthening climate-resilient health systems; (3) Monitoring, surveillance, and evaluation; and (4) risk communication. Research approaches need to be transdisciplinary, multi-scalar, inclusive, equitable, and broadly communicated. Promoting resilient and sustainable development are critical for achieving human and planetary health.

Forest disturbance and vector transmitted diseases in the lowland tropical rainforest of central Panama.

OBJECTIVE: To explore possible changes in the community attributes of haematophagous insects as a function of forest disturbance. We compare the patterns of diversity and abundance, plus the behavioural responses of three epidemiologically distinct vector assemblages across sites depicting various levels of forest cover. METHODS: Over a 3-year period, we sampled mosquitoes, sandflies and biting-midges in forested habitats of central Panama. We placed CDC light traps in the forest canopy and in the understorey to gather blood-seeking females. RESULTS: We collected 168 405 adult haematophagous dipterans in total, including 26 genera and 86 species. Pristine forest settings were always more taxonomically diverse than the disturbed forest sites, confirming that disturbance has a negative impact on species richness. Species of Phlebotominae and Culicoides were mainly classified as climax (i.e. forest specialist) or disturbance-generalist, which tend to decrease in abundance along with rising levels of disturbance. In contrast, a significant portion of mosquito species, including primary and secondary disease vectors, was classified as colonists (i.e. disturbed-areas specialists), which tend to increase in numbers towards more disturbed forest habitats. At pristine forest, the most prevalent species of Phlebotominae and Culicoides partitioned the vertical niche by being active at the forest canopy or in the understorey; yet this pattern was less clear in disturbed habitats. Most mosquito species were not vertically stratified in their habitat preference. CONCLUSION: We posit that entomological risk and related pathogen exposure to humans is higher in pristine forest scenarios for Culicoides and Phlebotominae transmitted diseases, whereas forest disturbance poses a higher entomological risk for mosquito-borne infections. This suggests that the Dilution Effect Hypothesis (DEH) does not apply in tropical rainforests where highly abundant, yet unrecognised insect vectors and neglected zoonotic diseases occur. Comprehensive, community level entomological surveillance is, therefore, the key for predicting potential disease spill over in scenarios of pristine forest intermixed with anthropogenic habitats. We suggest that changes in forest quality should also be considered when assessing arthropod-borne disease transmission risk.

OBJECTIF: Explorer les changements possibles dans les attributs communautaires des insectes hématophages en fonction de la perturbation des forêts. Nous comparons les modèles de diversité et d'abondance, ainsi que les réponses comportementales de trois assemblages de vecteurs épidémiologiquement distincts sur des sites illustrant divers niveaux de couverture forestière. MÉTHODES: Au cours d'une période de trois ans, nous avons échantillonné des moustiques, des phlébotomes et des moucherons piqueurs dans les habitats forestiers du centre de Panama. Nous avons placé des pièges à lumière CDC dans la canopée de la forêt et dans le sous-étage pour recueillir les femelles en quête de sang. RÉSULTATS: Nous avons collecté un total de 168.405 diptères hématophages adultes, dont 26 genres et 86 espèces. Les environnements de forêt intacts étaient toujours plus diversifiés du point de vue taxonomique que les sites forestiers perturbés, confirmant que les perturbations avaient un impact négatif sur la richesse en espèces. Les espèces de phlébotome et Culicoïdes étaient principalement classés comme climax (spécialiste de la forêt) ou généralistes de perturbation, qui ont tendance à diminuer en abondance parallèlement aux niveaux croissants de perturbation. En revanche, une partie importante des espèces de moustiques, y compris les vecteurs primaires et secondaires de maladies, a été classée dans la catégorie des colons (c'est-à-dire spécialistes des zones perturbées), qui ont tendance à se multiplier vers des habitats forestiers plus perturbés. Dans la forêt vierge, les espèces de phlébotomes et Culicoïdes les plus répandues cloisonnaient la niche verticale en étant actives dans la canopée de la forêt ou dans le sous-étage; pourtant, cette tendance était moins nette dans les habitats perturbés. La plupart des espèces de moustiques n'étaient pas stratifiées verticalement dans leur préférence d'habitat. CONCLUSION: Nous estimons que le risque entomologique et l'exposition associée des agents pathogènes à l'homme est plus élevé dans les scénarios de forêt vierge pour les maladies transmises par les phlébotomes et Culicoïdes, alors que la perturbation des forêts pose un risque entomologique plus élevé pour les infections transmises par les moustiques. Cela suggère que l'hypothèse de l'effet de dilution ne s'applique pas dans les forêts tropicales humides où se reproduisent très abondamment les insectes vecteurs, mais non reconnus, et où des maladies zoonotiques négligées surviennent. Une surveillance entomologique approfondie au niveau de la communauté est donc la clé pour prédire le potentiel de propagation des maladies dans des scénarios de forêt vierge mélangée à des habitats anthropiques. Nous suggérons que les changements dans la qualité des forêts soient également pris en compte lors de l'évaluation du risque de propagation de maladies transmises par les arthropodes.

Disturbance and mosquito diversity in the lowland tropical rainforest of central Panama.

The Intermediate Disturbance Hypothesis (IDH) is well-known in ecology providing an explanation for the role of disturbance in the coexistence of climax and colonist species. Here, we used the IDH as a framework to describe the role of forest disturbance in shaping the mosquito community structure, and to identify the ecological processes that increase the emergence of vector-borne disease. Mosquitoes were collected in central Panama at immature stages along linear transects in colonising, mixed and climax forest habitats, representing different levels of disturbance. Species were identified taxonomically and classified into functional categories (i.e., colonist, climax, disturbance-generalist, and rare). Using the Huisman-Olff-Fresco multi-model selection approach, IDH testing was done. We did not detect a unimodal relationship between species diversity and forest disturbance expected under the IDH; instead diversity peaked in old-growth forests. Habitat complexity and constraints are two mechanisms proposed to explain this alternative postulate. Moreover, colonist mosquito species were more likely to be involved in or capable of pathogen transmission than climax species. Vector species occurrence decreased notably in undisturbed forest settings. Old-growth forest conservation in tropical rainforests is therefore a highly-recommended solution for preventing new outbreaks of arboviral and parasitic diseases in anthropic environments.

Enzootic Arbovirus Surveillance in Forest Habitat and Phylogenetic Characterization of Novel Isolates of Gamboa Virus in Panama.

Landscape changes occurring in Panama, a country whose geographic location and climate have historically supported arbovirus transmission, prompted the hypothesis that arbovirus prevalence increases with degradation of tropical forest habitats. Investigations at four variably degraded sites revealed a diverse array of potential mosquito vectors, several of which are known vectors of arbovirus pathogens. Overall, 675 pools consisting of 25,787 mosquitoes and representing 29 species from nine genera (collected at ground and canopy height across all habitats) were screened for cytopathic viruses on Vero cells. We detected four isolates of Gamboa virus (family:Bunyaviridae; genus:Orthobunyavirus) from pools of Aedeomyia squamipennis captured at canopy level in November 2012. Phylogenetic characterization of complete genome sequences shows the new isolates to be closely related to each other with strong evidence of reassortment among the M segment of Panamanian Gamboa isolates and several other viruses of this group. At the site yielding viruses, Soberanía National Park in central Panama, 18 mosquito species were identified, and the predominant taxa included A. squamipennis,Coquillettidia nigricans, and Mansonia titillans.

The effectiveness of permethrin-treated deer stations for control of the Lyme disease vector Ixodes scapularis on Cape Cod and the islands: a five-year experiment.

BACKGROUND: The use of animal host-targeted pesticide application to control blacklegged ticks, which transmit the Lyme disease bacterium between wildlife hosts and humans, is receiving increased attention as an approach to Lyme disease risk management. Included among the attractive features of host-targeted approaches is the reduced need for broad-scale pesticide usage. In the eastern USA, one of the best-known of these approaches is the corn-baited "4-poster" deer feeding station, so named because of the four pesticide-treated rollers that surround the bait troughs. Wildlife visitors to these devices receive an automatic topical application of acaricide, which kills attached ticks before they can reproduce. We conducted a 5-year controlled experiment to estimate the effects of 4-poster stations on tick populations in southeastern Massachusetts, where the incidence of Lyme disease is among the highest in the USA. METHODS: We deployed a total of forty-two 4-posters among seven treatment sites and sampled for nymph and adult ticks at these sites and at seven untreated control sites during each year of the study. Study sites were distributed among Cape Cod, Martha's Vineyard, and Nantucket. The density of 4-poster deployment was lower than in previous 4-poster studies and resembled or possibly exceeded the levels of effort considered by county experts to be feasible for Lyme disease risk managers. RESULTS: Relative to controls, blacklegged tick abundance at treated sites was reduced by approximately 8.4%, which is considerably less than in previous 4-poster studies. CONCLUSIONS: In addition to the longer duration and greater replication in our study compared to others, possible but still incomplete explanations for the smaller impact we observed include the lower density of 4-poster deployment as well as landscape and mammalian community characteristics that may complicate the ecological relationship between white-tailed deer and blacklegged tick populations.

Amblyomma tapirellum (Acari: Ixodidae) collected from tropical forest canopy.

Free-ranging ticks are widely known to be restricted to the ground level of vegetation. Here, we document the capture of the tick species Amblyomma tapirellum in light traps placed in the forest canopy of Barro Colorado Island, central Panama. A total of forty eight adults and three nymphs were removed from carbon dioxide-octenol baited CDC light traps suspended 20 meters above the ground during surveys for forest canopy mosquitoes. To our knowledge, this represents the first report of questing ticks from the canopy of tropical forests. Our finding suggests a novel ecological relationship between A. tapirellum and arboreal mammals, perhaps monkeys that come to the ground to drink or to feed on fallen fruits.