Glasgow Area Research Articles

Denise Coia: mental health champion and chair of the Royal College of Psychiatrists in Scotland

Credit: Healthcare Improvement Scotland In 1987 Denise Coia became a consultant clinical psychiatrist in the deprived Gorbals area of south Glasgow. Passionate about mental health, she was determined to transform...

"The state They're in": Unpicking fantasy paradigms of health improvement interventions as tools for addressing health inequalities.

Globally, it is recognised that the fundamental causes of iniquitous health outcomes lie within unequal distributions of wealth and power. Internationally, however, policies and interventions persist in individualising the inequalities problem and targeting individual behaviours as the main solution. This approach has been argued to represent ‘Fantasy Paradigms’. This paper explores one example of such ‘Fantasy’ intervention from the perspective of health practitioners. Further, it explores opportunities for deepening practitioner understandings of the socio-political determination of health. Data were collected through in-depth interviews with 47 professionals involved in delivering a social prescribing programme in poor areas of Glasgow, Scotland. Data were analysed thematically across and within transcripts. Narratives highlighted different explanatory types concerning how the intervention could tackle health inequalities including: firm commitment to individualised approaches; hopeful pessimism; the social-determinants-of-health as an unpoliticised and nondeterministic backdrop to poor health; and finally, incomplete understanding of the social gradient as a population concept. Disrupted narratives of the social determination of health were also evident. This paper contributes new insights to existing debates on health inequalities discourse. These are conceptually important and identify opportunities for sharpening practitioner understanding of the social determinants of health which could in turn contribute to better, non-stigmatising primary care. It argues that re-engaging communities of practice with what is meant by determination of health is necessary and that there is a need to de-couple the policy aim of reducing health inequalities from the delivery of structurally competent and equality-focused public services.

New records of sessile earthstars (Geastrum fimbriatum) and collared earthstars (Geastrum triplex) from the Glasgow area, Scotland

New records of sessile earthstars (Geastrum fimbriatum) and collared earthstars (Geastrum triplex) from the Glasgow area, Scotland

A feasibility cluster randomised controlled trial of a preschool obesity prevention intervention: ToyBox-Scotland

BackgroundHigh levels of childhood obesity have been observed globally over the last three decades. Preschools are promising settings to implement obesity prevention interventions in the early years. The aim of this study was to test the feasibility of a cluster randomised controlled trial of the ToyBox-Scotland preschool obesity prevention intervention.MethodsSix preschools in predominantly deprived areas of Glasgow, UK, were randomised to either the ToyBox intervention (n = 3) or usual curriculum control group (n = 3). The intervention ran for 18 weeks from March–June 2018, and consisted of practitioner-led physical activity and sedentary behaviour sessions in preschools, with an additional interactive home component. Primary outcome measures were intervention fidelity, recruitment rates, attrition rates, and compliance with trial procedures. Secondary outcomes were body mass index (BMI) z-score, bioelectrical impedance analysis (BIA), objectively measured physical activity and sedentary time via activPAL accelerometer, and parent-reported home eating, snacking, and water consumption.ResultsThe preschool component of the intervention was implemented with high fidelity (64%), while the home component was implemented with low fidelity (41%). A cluster-level recruitment rate of 10% was achieved, and the individual-level recruitment rate was 18% (42/233 children, mean age 4.4 years; 17 girls). The attrition rate was 14%, and compliance rates varied considerably by the outcome. Compliance was highest for BMI (86%), while 19% of the sample returned valid accelerometer data for both baseline and follow-up and the parental questionnaire response rate was 23%. Both intervention and control groups showed small increases in BMI z-scores at follow-up of 0.02 and 0.06, respectively. Both groups had small decreases in physical activity and increases in sedentary time at follow-up.ConclusionsBefore progression to an effectiveness trial, additional procedures should be considered to improve recruitment rates, compliance with outcome measures, and implementation of the home-based component of the ToyBox-Scotland intervention.Trial registrationISRCTN12831555

Effectiveness of Community-Links Practitioners in Areas of High Socioeconomic Deprivation.

To assess the effect of a primary care-based community-links practitioner (CLP) intervention on patients' quality of life and well-being. Quasi-experimental cluster-randomized controlled trial in socioeconomically deprived areas of Glasgow, Scotland. Adult patients (aged 18 years or older) referred to CLPs in 7 intervention practices were compared with a random sample of adult patients from 8 comparison practices at baseline and 9 months. health-related quality of life (EQ-5D-5L, a standardized measure of self-reported health-related quality of life that assesses 5 dimensions at 5 levels of severity). well-being (Investigating Choice Experiments for the Preferences of Older People Capability Measure for Adults [ICECAP-A]), depression (Hospital Anxiety and Depression Scale, Depression [HADS-D]), anxiety (Hospital Anxiety and Depression Scale, Anxiety [HADS-A]), and self-reported exercise. Multilevel, multiregression analyses adjusted for baseline differences. Patients were not blinded to the intervention, but outcome analysis was masked. Data were collected on 288 and 214 (74.3%) patients in the intervention practices at baseline and follow-up, respectively, and on 612 and 561 (92%) patients in the comparison practices. Intention-to-treat analysis found no differences between the 2 groups for any outcome. In subgroup analyses, patients who saw the CLP on 3 or more occasions (45% of those referred) had significant improvements in EQ-5D-5L, HADS-D, HADS-A, and exercise levels. There was a high positive correlation between CLP consultation rates and patient uptake of suggested community resources. We were unable to prove the effectiveness of referral to CLPs based in primary care in deprived areas for improving patient outcomes. Future efforts to boost uptake and engagement could improve overall outcomes, although the apparent improvements in those who regularly saw the CLPs may be due to reverse causality. Further research is needed before wide-scale deployment of this approach.

Re-emergence of HIV related to injecting drug use despite a comprehensive harm reduction environment: a cross-sectional analysis

In 2015, an outbreak of HIV was identified among people who inject drugs (PWID) in the Greater Glasgow and Clyde (GGC) area of Scotland, an area which distributes more than 1 million needles and syringes per year. This is the largest such incident in the UK for 30 years. Here, we provide an epidemiological analysis of the impact of the outbreak on HIV prevalence trends in the population and the individual and environmental risk factors associated with infection. Four cross-sectional, anonymous, bio-behavioural surveys of almost 4000 PWID attending services providing injecting equipment across GGC between 2011 and 2018 were analysed. Participants were recruited by trained independent interviewers and eligible if they had a history of injecting drug use, either current (within the past 6 months) or historical. Interviewers asked participants questions about demographics, behaviours, and service use and to give a dried blood spot sample that was tested anonymously for the presence of blood-borne viruses. Our primary outcome measure was HIV infection status, as determined by the dried blood spot sample. We removed duplicates and participants with missing data and used all remaining participants to examine trends in prevalence of HIV infection, risk behaviours, and intervention coverage. We then did multivariate analysis with adjusted and unadjusted logistic regression to determine individual and environmental factors associated with HIV infection. The overall GGC sample comprised 3641 PWID; data from 2712 PWID were available for multivariate analysis after further removal of duplicate participants and missing data. Between 2011 and 2018, HIV prevalence in GGC rose from 0·1% (95% CI 0·0-0·6) to 4·8% (3·4-6·2) overall, and from 1·1% (0·2-6·2) to 10·8% (7·4-15·5) in Glasgow city centre. Over the same period, the prevalence of cocaine injecting in all individuals in GGC in our sample rose from 16% (129/805) to 50% (291/583) overall, and from 37% (26/70) to 77% (117/153) in Glasgow city centre. HIV infection was more likely among PWID who had participated in surveys after the start of the outbreak in 2014 (adjusted odds ratio 3·4, 95% CI 1·7-6·7; p=0·00052), been homeless in the past 6 months (3·0, 1·7-5·0; p<0·0001), had had more than five incarcerations since they first began injecting (2·1, 1·2-3·7; p=0·0098); and had injected cocaine within the past 6 months (6·7, 3·8-12·1; p<0·0001). Age (per 1-year increase) was also a significant factor (1·1, 1·0-1·1; p=0·0016) but sex was not (1·7, 0·9-3·2; p=0·083). Despite high coverage of harm reduction interventions, Glasgow has experienced a rapid rise in prevalence of HIV among its PWID population, associated with homelessness, incarceration, and a major shift to injection of cocaine. Robust surveillance through regular HIV testing of high-risk populations is crucial to ensure outbreaks are detected and rapid responses are informed by the best available evidence. Health Protection Scotland.

Not so welcome here? Modelling the impact of ethnic in-movers on the length of stay of home-owners in micro-neighbourhoods

This paper considers the length of stay of home-owners with white British names in the 40% most-deprived census areas of Glasgow, Scotland. We estimate the impact of ethnically ‘other’ name-group inflows through property purchases at the micro-neighbourhood level. We use a novel longitudinal data set, constructed from the population of home-buyers recorded in all property transaction records from 2003 to 2014, from which we impute ethnicity using name-matching software. We estimate how the survival time (length of ownership) of home-owners with white British names is affected by in-migration of house-buyers from different ethnic name-groups into the micro-neighbourhood, defined as a 50 m radius around each home. Results suggest a complex set of associations between ethnically ‘other’ purchasers/in-movers (based on name groups) and duration of home-ownership for white-British named owners. The most consistent finding is for in-moving purchasers with Pakistani (primarily Muslim) names, which tend to have a relatively large accelerant effect on the moving propensity of home-owners who have white British names. This was true in areas of both high and low non-white ethnic population share. We also find evidence of nonlinearity in this relationship: the accelerant effect diminishes with each additional in-move from purchasers with Pakistani names. The name group with the largest overall accelerant effect was for in-movers with non-white Other names, which were also primarily Muslim in origin, though this effect was less consistent across models.

Absence of holistic sexual health understandings among men and women in deprived areas of Scotland: qualitative study

BackgroundThere is a growing evidence base for the need for a holistic approach to sexual health improvement, but the challenges for realising this in the ‘real world’ may be harder in some communities than others. We examined sexual health understandings and behaviours among adult men and women in deprived areas of Scotland.MethodsThematic analysis, using the constant comparative method, of qualitative, semi-structured in-depth interviews with 19 men and 16 women aged 18–40 years from the most deprived areas of Glasgow, Edinburgh, Dundee, and three Highland towns.ResultsEven though most had been shown images designed to facilitate discussion about sexual consent and verbal/physical abuse, when first asked, participants overwhelmingly equated ‘sexual health’ with the avoidance of sexually transmitted infections (STIs) and pregnancy. Most of the women interviewed went on to locate their accounts of sexual health within a broader, social account of relationships that in an ideal world, in contrast with their everyday lives, were based on respect and freedom from violence. They expressed desires for more positive relationships, based on open communication and trust, choice and freedom from coercion. A few men did accept a broader definition of sexual health, but others actively resisted it and placed the onus to enact choices and freedom from coercion on women rather than men.ConclusionsIn the first UK study to examine understandings of holistic sexual health among adults living in deprived areas, we found a disjuncture between men and women. These findings suggest that, as a society, we are failing to equip people to enhance their own, and others’, sexual health and wellbeing in its broadest sense. New efforts to emphasise the breadth of sexual health are required, but addressing these complex issues, especially where there are negative underlying gender norms to challenge, will require multi-level interventions targeting individual, community and system levels.

The collared earthstar (Geastrum triplex) in the Glasgow area, Scotland

The collared earthstar (Geastrum triplex) in the Glasgow area, Scotland

The powdercap strangler Squamanita paradoxa, a bizarre parasitic mushroom found for the first time in the Glasgow area

The powdercap strangler Squamanita paradoxa, a bizarre parasitic mushroom found for the first time in the Glasgow area

Not so Welcome Here? Modelling the Impact of Ethnic In-Movers on the Length of Stay of Home-Owners in Micro-Neighbourhoods

This paper considers the length of stay of home-owners with white British names in the 40% most deprived census areas of Glasgow, Scotland. We estimate the impact of ethnically ‘other’ name-group inflows through property purchases at the micro-neighbourhood level. We use a novel longitudinal dataset, constructed from the population of home-buyers recorded in all property transaction records from 2003 to 2014, from which we impute ethnicity using name-matching software. We estimate how the survival time (length of ownership) of homeowners with white British names is affected by in-migration of house-buyers from different ethnic name-groups into the micro-neighbourhood, defined as a 50m radius around each home. Results suggest a complex set of associations between ethnically “other” purchasers/inmovers (based on name groups) and duration of home-ownership. The most consistent finding is for in-moving purchasers with Pakistani (primarily Muslim) names, which tend to have a relatively large accelerant effect on the moving propensity of homeowners that have white British names. This was true in areas of both high and low non-white ethnic population share. We also find evidence of nonlinearity in this relationship: the accelerant effect diminishes with each additional in-move from purchasers with Pakistani names. The name group with the largest overall accelerant effect was for inmovers with non-white Other names, which were also primarily Muslim in origin, though this effect was less consistent across models.

Water vole (Arvicola amphibius) abundance in grassland habitats of Glasgow

Water vole (Arvicola amphibius) populations have undergone a serious decline throughout the UK, and yet a stronghold of these small mammals is found in the greater Easterhouse area of Glasgow. The water voles in this location are mostly fossorial, living a largely subterranean existence in grasslands, rather than the more typical semi-aquatic lifestyle in riparian habitats. In this study, we carried out capture-mark-recapture surveys on water voles at two sites: Cranhill Park and Tillycairn Drive. We made a total of 62 captures including retraps, and the resulting population estimates were 78 individuals (95% confidence interval 41-197) for Cranhill Park and 42 individuals (20-141) for Tillycairn Drive. From these figures we estimated a population density of water voles, which appeared to be higher than other reports from the UK. Despite the difficulties of sampling in urban environments that resulted in relatively low capture rates, our data suggest that the greater Easterhouse area of Glasgow holds water voles at relatively high population densities. These results will inform future conservation in the City of Glasgow and surrounding areas, as well as raise awareness of important water vole populations in urban environments.

“We’d get slagged and bullied”: understanding barriers to volunteering among young people in deprived urban areas

This article explores barriers to formal volunteering opportunities among young people, aged 12–18, in deprived urban areas in Glasgow, Scotland. It draws on qualitative fieldwork conducted with young volunteers, non-volunteers and youth workers. The article employs Bourdieu’s concept of ‘habitus’ to analyse how objective conditions and subjective dispositions created obstacles to participation. Findings indicate that participants were constrained from accessing volunteering due to: resource issues in youth organisations; a lack of support from schools; a lack of information; and restrictions on their spatial mobilities. These constraints provided conditions in which volunteering became subject to informal penalties. These were not, however, experienced in a uniform manner but intersected with gender and individual trajectories to create varying opportunities for volunteering.

Is the popularity of social networking services beneficial for public health? Focusing on active travel and BMI

Social networking services (SNSs) can affect people's behaviour in a variety of ways; and through this their health outcomes. People generate and are exposed to content which circulates easily among a large, geographically dispersed population. They can also engage in supportive or competitive activities with their connections and the wider community. This online activity may lead to changes in behaviour and positive health outcomes e.g., exercising more or eating more healthily. Engaging with a SNS may also lead to negative outcomes such as depression, addiction, and less participation in offline social communities. As the number of SNS users has been increasing dramatically, it is important to understand if this will be beneficial or detrimental for public health. In this study, we examine how the frequency of SNS use is associated with active travel (i.e., walking and cycling) and body mass index (BMI) in the Glasgow and Clyde Valley Planning area, Scotland. We employ both a self-reported measure of active travel from a travel diary (N = 1684) and an objective measure of average walking hours from Global Positioning System (GPS) data (N = 282) collected in 2015. These are analysed with statistical models (i.e., binomial logistic regression, multinomial logistic regression and linear regression models). We find that there is no significant association between the frequency of SNS use and our subjective measure of active travel, while people who intensively use SNS are more likely to be obese than non-users. However, analyses with an objective measure of average walking hours (GPS) show that people who intensively use SNS spend less time walking and tend to be obese, calling for further analyses.

Books: Poverty Safari: Understanding the Anger of Britain's Underclass: Structure Versus Agency.

Darren McGarvey Luath Press Ltd, 2017, PB , 224 pp , £6.29, 978-1912147038 It is often said that statistics are human beings with the tears wiped away. Halfway through Poverty Safari: Understanding the Anger of Britain’s Underclass , the first book by the Scottish rapper, writer, and columnist Darren McGarvey, the author provides us with some statistics. Now in his mid-thirties, he looks back at his upbringing in Pollok, a so-called ‘deprived’ area of Glasgow, with his four siblings: ‘Four out of five have experienced alcohol or substance misuse problems at some point. Five have experienced long term financial problems which involve debilitating debt or defaults and poor credit history.’ The list goes on: ‘Five have experienced abuse and neglect at the …

Entering and leaving employment in deprived neighbourhoods undergoing area regeneration

Concentrations of worklessness have been persistent in the UK for several decades but have not been tackled effectively by policy. An individualised approach to unemployment has existed, alongside employment policies that lack a strong geographical component. A reliance on area-based regeneration programmes has shifted from a property-led approach to a holistic approach, with the potential to address a range of factors associated with employment. To gauge the effectiveness and appropriateness of holistic area regeneration, this paper uses longitudinal survey data to examine movements into and out of employment for people living in deprived areas of Glasgow with concentrated worklessness and subject to area regeneration. There were modest net gains to employment over time in the study areas, and such gains were positively associated with traditional elements of regeneration such as housing improvements and community empowerment. However, other components of regeneration assumed to aid employment, such as social networks and participation in training, were found to have no effect. Other factors that were associated both with entering and leaving employment feature less frequently within regeneration programmes and require more integration into future approaches, particularly increasing physical activity among populations, helping people cope with physical and mental health issues, and improving transport and mobility.

Measurement of diesel combustion-related air pollution downwind of an experimental unconventional natural gas operations site

Background & aimUnconventional natural gas (UNG) extraction activities have considerable potential to affect air quality. However, there are few published quantitative observations of the magnitude of such impacts. To provide context, we compared measured exposures to diesel engine exhaust close to industrial fracking equipment at an UNG training simulation site in Łowicz, Poland to pedestrian exposures to traffic-related air pollution in the city centre of Glasgow, UK. MethodsWe made mobile and static measurements at varying distances from sources in both of the above locations with a portable aethalometer (Aethlabs AE51) for black carbon (BC) and portable monitors (Aeroqual Series-500) for nitrogen dioxide (NO2) and ozone (O3). Duplicate BC measurements were compared with NO2 observations, after correction of the NO2 sensor response for O3 interference effects. ResultsDuplicate BC instruments provided similar real-time measurements (r = 0.92), which in turn were relatively highly correlated with NO2 observations at 5-min temporal resolution at the UNG experimental site (r = 0.75) and on the walking route in Glasgow city centre (r = 0.64) suggesting common diesel sources for NO2 and BC in both locations. Average BC and NO2 concentrations measured approximately 10 m downwind of diesel fracking pumps were 11 and 113 μg/m3 respectively. These concentrations were approximately 37 times and 4 times higher than upwind background BC and NO2 concentrations at the site; and approximately 3 times higher than average BC and NO2 concentrations measured in traffic influenced areas in Glasgow. ConclusionsMarked elevations of BC and NO2 concentrations were observed in downwind proximity to industrial fracking equipment and traffic sources. This suggests that exposure to diesel engine exhaust emissions from fracking equipment may present a significant risk to people working on UNG sites over extended time periods. The short time resolution of the portable instruments used enabled identification of likely sources of occupational and environmental exposure to combustion-related air pollutants.

Social and spatial mobility and self-reported heath in older-age: linkage of the Scottish Longitudinal Study to the Scottish Mental Survey 1947

BackgroundThere is debate within the literature as to whether social mobility inflates or constrains health inequalities. The role of geographical mobility is unknown.&#x0D; ObjectivesWe were interested in exploring how spatial and social mobility might impact on health in older age using linked administrative and cohort data.&#x0D; MethodsThe Scottish Mental Survey 1947 (a 1936 birth cohort of 70,805 individuals with age 11 cognitive ability test scores) was linked to the Scottish Longitudinal Study (a semi-random sample of 5.3% of the Scottish population), and the 1939 register to obtain measures of occupation and geographical location in 1939 and 1991. We examined the movement between three geographical areas (Edinburgh, Glasgow, Other) in Scotland. Four social mobility trajectories were derived. We modelled the relationship between social and geographic mobility and likelihood of having self-reported limiting long term illness (LLTI) at age 65.&#x0D; FindingsThose who were geographically mobile to Edinburgh had the lowest rates of self-reported LLTI and those who remained resident in the Glasgow area had the highest rates. The lowest and highest rates of LLTI were found in the socially-static at the top and bottom of the social scale respectively, with intermediate rates seen in the upwardly and downwardly mobile. However neither social nor spatial mobility were significantly associated with health in later life in the fully adjusted model when highest educational qualifications and cognitive ability were included. Being female, having higher education qualifications and being in a higher social class in childhood and adulthood reduced the likelihood of poor health at age 65.&#x0D; ConclusionsAlthough both social class and geographical location were associated with the likelihood of LLTI in later life, social and spatial mobility were not, when factors such as education and cognitive ability were controlled for.

Tackling health inequalities in access to Child and Adolescent Mental Health Services (CAMHS) using neighbourhood profiling of administrative data

BackgroundReducing health inequalities includes addressing access to and use of services, including considering how deprivation may affect service engagement and referrals. NHS Greater Glasgow and Clyde (NHSGGC) are close to the national average for most CAMHS benchmarking indicators, including waiting times, and referrals received and accepted. When comparing UK rates of Did Not Attends (DNA), however, NHSGGC were fourth highest in 2016. More detailed analysis of service use was thus of interest. While some service and patient risk factors are known, this study used data from NHSGGC’s electronic children’s health record system to develop neighbourhood profiles of access and use.&#x0D; Objectives&#x0D; &#x0D; To analyse activity within communities so health resourcescan be best targeted.&#x0D; To help clinical teams plan services and develop newmodels matched to local need.&#x0D; &#x0D; MethodsPatient-level administrative data was linked to geographic and population data to identify outlying areas of demand. Data on referrals, open cases, appointments and DNAs were extracted and population-based analyses undertaken with 120,000 data points, linked to 273 neighbourhoods across NHSGGC.&#x0D; FindingsGeomaps were used to highlight variation in activity, demand and population at neighbourhood and NHSGGC levels. Unexpectedly low levels of population reach (open cases/population under 18s) were found in some areas (Govanhill, 0.5%, relative to NHSGGC, 1.94%). Yet, the high level of DNAs in some East Glasgow areas is as one would predict given deprivation levels.&#x0D; ConclusionsFindings have been used to identify potential improvements and to target communities who could benefit most. For example, West Dunbartonshire teams noticed high DNA rates in two neighbourhoods, both geographically distant from clinics. Satellite clinics have been introduced to improve attendance by reducing travel time and costs for families.&#x0D; Neighbourhood profiles have proved valuable in highlighting population based trends and supporting comparisons locally and relative to NHSGGC wide benchmarks.

Longitudinal association between change in the neighbourhood built environment and the wellbeing of local residents in deprived areas: an observational study

BackgroundFeatures of the urban neighbourhood influence the physical, social and mental wellbeing of residents and communities. We explored the longitudinal association between change to the neighbourhood built environment and the wellbeing of local residents in deprived areas of Glasgow, Scotland.MethodsA cohort of residents (n = 365; mean age 50 years; 44% male; 4.1% of the 9000 mailed surveys at baseline) responded to a postal survey in 2005 and 2013. Wellbeing was assessed with the mental (MCS-8) and physical (PCS-8) components of the SF-8 scale. We developed software to aid identification of visible changes in satellite imagery occurring over time. We then used a Geographical Information System to calculate the percentage change in the built environment occurring within an 800 m buffer of each participant’s home.ResultsThe median change in the neighbourhood built environment was 3% (interquartile range 6%). In the whole sample, physical wellbeing declined by 1.5 units on average, and mental wellbeing increased by 0.9 units, over time. In multivariable linear regression analyses, participants living in neighbourhoods with a greater amount of change in the built environment (unit change = 1%) experienced significantly reduced physical (PCS-8: -0.13, 95% CI -0.26 to 0.00) and mental (MCS-8: -0.16, 95% CI -0.31 to − 0.02) wellbeing over time compared to those living in neighbourhoods with less change. For mental wellbeing, a significant interaction by baseline perception of financial strain indicated a larger reduction in those experiencing greater financial strain (MCS-8: -0.22, 95% CI -0.39 to − 0.06). However, this relationship was reversed in those experiencing lower financial strain, whereby living in neighbourhoods with a greater amount of change was associated with significantly improved mental wellbeing over time (MCS-8: 0.38, 95% CI 0.04 to 0.72).ConclusionsOverall, we found some evidence that living in neighbourhoods experiencing higher levels of physical change worsened wellbeing in local residents. However, we found a stronger negative relationship in those with lower financial security and a positive relationship in those with higher financial security. This is one of few studies exploring the longitudinal relationship between the environment and health.