What is the problem?
Healthcare is responsible for 6.6% of NSW's total carbon emissions and 8% of its waste, with 25% of carbon emissions coming from NSW hospitals. Currently only 60% of healthcare is high value, with 40% considered wasteful, low value or harmful. As each test or procedure produces a carbon footprint, low value care creates an avoidable environmental cost, in addition to patient risks and financial costs. To achieve net zero healthcare, health systems must decarbonize, and cull low value care. 

How has the problem been addressed?
In the first significant, strategic investment by a state health department towards achieving net zero healthcare, a partnership between NSW Health’s Climate Risk and Net Zero Unit and researchers at Wiser Healthcare was formed in January 2023 with joint funding. We support ten projects across metropolitan and regional NSW public hospital in clinical areas including allied health, emergency medicine, intensive care, medical imaging, medical and nursing services. Example projects: 1) The Gloves Off project – a staff intervention to reduce unnecessary use of non-sterile gloves (nursing); 2) Optimising Pharmaceutical Waste Management to reduce waste and avoid water and soil contamination (pharmacy); 3) Comparison of single use versus reusable surgical supplies (surgery); 4) Reducing energy consumption in medical (CT) imaging; 5) Reducing unnecessary pathology testing (Emergency Dept) 6) Reducing carbon footprint of volatile anaesthetic gases.

 Projects are led by clinical champions who act as change agents while conducting projects suitable for scale up. Key principles for this partnership: a multidisciplinary approach, codesigned interventions and evaluations, team-based support and development of research capability.

How is this being used in practice?
After 18 months, the Net Zero Partnership projects are demonstrating reductions in carbon emissions, waste, electricity consumption and financial costs. The co-creation enhances relevance and potential for translation, while the evaluations provide implementation and effectiveness data for scale up across NSW and interstate.

Future actions?
We have demonstrated the potential of practice-research partnerships. With financial support from Departments of Health in other Australian states and territories, such partnerships can help realise the goal of the National Health and Climate Strategy (released in December 2023) to achieve net zero healthcare in line with international climate change commitments. Future partnerships should ensure that policy partners set priority targets, research partners lead design of interventions and evaluations, and clinician partners lead intervention implementation.

Bushfires and bushfire smoke pose substantial risks to the physical and mental health of exposed populations, especially in identified high-risk groups. Enhanced community-level knowledge and response capability may promote exposure reduction and protect health. However, few interventions exist to achieve this goal. We developed a free online short course, ‘Bushfires and Your Health’, and piloted it with older adults as an at-risk group.

In our pilot, we used a participant (intervention) group and a control group (who did not undertake the course), evaluating factors associated with course enrolment and completion, course satisfaction, level of understanding, the likelihood of increased bushfire knowledge, and the likelihood of participants undertaking risk-mitigating and health-promoting actions. We (1) used a pre- post-course survey in both the intervention group and control group; (2) used a post-course completion feedback survey in the intervention group only; and (3) analysed discussion board submissions from course participants for evidence of course-related behaviour change. Participants reported high rates of course satisfaction and understanding. Course enrolment was significantly and positively associated with several demographic characteristics, including being retired, living near bushland and having a bushfire survival plan. Course completion was associated with an increase in bushfire knowledge, and with participants undertaking new actions, including downloading and using an air quality app, developing a bushfire survival plan and making preparations around the home. Participant feedback noted beneficial behaviour change intention, for example “This course has definitely convinced me to leave early and not try to be a martyr.”

Based on this pilot, we offered free community-wide courses over the 2022-23 and 2023-24 summer seasons. To date, over 1000 people have enrolled in the course. In 2023, critical material from this course was translated into languages commonly spoken by those most recently arrived into Tasmania (Nepali, Farsi, Arabic, Karen, Oromo and Tigrinya). This material is used to assist newly arrived migrants to become familiar with the bushfire risks inherent in Tasmania.

Free delivery of this course is funded until 2026 and offers a model of how well-designed online education can successfully build community health capacity to adapt to a changing climate.

Landscape fires are increasing in frequency and intensity globally, as the result of a changing climate. An increasing number of people, especially those living at the interface between populated urban settlements and fire-prone vegetation, are exposed to fire disasters. Relocation, evacuation and adaptation strategies are therefore becoming a pressing issue for local, regional and national governments and at-risk communities, resulting in individuals being required to make plans in response to the threat of landscape fires. These personal decisions regarding if and when to relocate to a safer place in response to the threat of fire have multiple social and cultural influences; however, little is understood about the role of an individual’s health status in shaping these decisions. In this study, we investigate associations between self-reported sociodemographic and health-related variables and landscape fire relocation intentions in Tasmania, Australia. Using data collected in the 2016 Tasmanian Population Health Survey, we implemented logistic regression modelling to characterise associations between variables, including overall health status, presence of a chronic medical condition, age group, gender, educational attainment, employment status, financial security, and intention to leave during a landscape fire threat. Reporting an intention to leave was more than three times higher among women than men. It was also significantly higher for people with higher versus lower educational attainment, and in those diagnosed with depression/anxiety, compared to those without. When stratified by gender, associations with chronic conditions, asthma and higher educational attainment were observed in men, while the association with anxiety/depression was elevated for women, without reaching statistical significance. Our research findings have been shared with the Tasmania Fire Service, who have carriage of local landscape fire-related safety messaging. To most effectively target safety messages, it is imperative that social, demographic and health differences can be considered in planning communication and messaging to residents in fire-prone areas.

What is the issue that requires public health action?

People who are homeless experience enormous health disparities, including a three-decade life expectancy gap and a high prevalence of chronic disease. Conventional public health campaigns rarely reach this population, who encounter barriers to healthcare access and healthy behaviours and who are rarely recognised as a priority group due to largely being invisible in general population health data.

What have we learned to address this issue, and how has this finding been derived?

Using rich longitudinal health data for 1,482 patients of a specialist homelessness primary care practice, we examined the prevalence and risk factors for preventable chronic conditions and barriers and enablers to health promotion salience and preventive health. Factors examined included tobacco use, blood pressure, diabetes assessment and cancer screening.

The prevalence of chronic disease risk factors and conditions is high, and many barriers to preventive healthcare access exist. Daily survival can take precedence, but many patients were interested and engaged in improving their health. Primary health care providers with established trust can be a valuable conduit for health promotion.

How has this been used in practice?

This research involved collaboration with a large provider of primary care services to people experiencing homelessness, with a shared commitment to increasing preventive health access and support for this population. Implications for public health programs are being shared and an advocacy strategy has been developed promoting recognition of people experiencing homelessness as a priority group in key national and state health strategies.

What actions should we take in the future?

Trauma, adversity and social exclusion contribute to the high prevalence of preventable disease in homeless populations and other vulnerable groups. Mainstream public health interventions should recognise this and be trauma-informed, and tailored strategies should be developed to reduce the preventable life expectancy gap.

Context and Aim:
The caesarean section (CS) rate in Australia is high, exceeding 38%. While CS offers lifesaving benefits in some cases, overuse can negatively impact population health. The short-term risks are well characterised, however a gap exists in understanding the long-term effects. This research aims to bridge this gap by synthesising existing evidence on the long-term effects of CS, considering not only individual health but also societal implications.

Methods and Analysis/Research Findings: We conducted a systematic scoping review, searching major databases for studies published after 2004. Studies comparing long-term outcomes (>12 months) of CS and vaginal birth in term pregnancies were included.

The review identified potential associations with increased risks of various health conditions for the offspring, including some cancers, asthma, allergies, infections, autoimmune diseases. Additionally, altered stress response, behavioural problems, and lower academic performance were observed in some cases, although findings were mixed. No significant associations were identified between CS and semen quality, depressive disorders, or empathetic behaviour.

For women, CS was linked to increased chronic pain, abnormal bleeding, adhesive disorders, hospitalisations for cancer, reduced fertility, endometriosis, and bowel obstructions. CS can negatively impact birth experience, leading to higher rates of PTSD, postpartum depression, and lower quality of life. Conversely, CS was associated with better pelvic floor function.

Overuse of CS raises concerns beyond individual health outcomes. Prophylactic antibiotics used during the surgery may contribute to the growing problem of antibiotic resistance, and they generate more carbon emissions and disposable medical waste compared to vaginal birth.

Translational Outcomes:
These findings highlight a variety of long-term consequences associated with CS, extending beyond the immediate delivery period and impacting individuals and society. There is a need to incorporate the cost of long-term adverse health effects into maternity policy creation.

Future Actions:
A holistic approach to reducing the CS rate is recommended. This includes reviewing care guidelines, promoting vaginal birth after caesarean, and increasing availability of midwifery continuity of care. Clinicians should ensure that women are aware of potential long-term health outcomes when obtaining informed consent for CS. Further research is needed to confirm some associations and to reveal the underlying mechanisms.

Context/Aim:

One quarter of young Australian children are vulnerable to developmental delay with significant geographical variance. Research highlights the importance of built environment features for determining developmental outcomes, however this differs by area-level disadvantage. The aim was to explore the lived experience of parents experiencing hardship using go-along interviews to understand how urban environments influence young children’s development.

Methods/Research findings:

19 parents of children under 6 years experiencing hardship were recruited via our partner service provider in Perth, WA. Service managers and support workers shared the recruitment information with clients of parenting workshops, young parents support services, parent and child centres, and a supported accommodation service.

Go-along interviews involve the researcher conducting a semi-structured interview whilst accompanying a participant on a day-to-day activity, allowing the researcher to use the surrounding environment as discussion points or question prompts. Interviews were conducted in November-December 2023, in a pre-determined location identified by the participant as a place where they and the child enjoy spending time together. Participants were asked about their reasons for visiting their chosen location, who they usually visit with, what they do on a typical visit and about how their chosen place may help their child ‘learn and grow’. Participants provided demographic information immediately after the interview. Field notes were taken by the interviewer and captured descriptions of the physical features of interview location, the types of people present in the location and their use of the space, and participants’ interactions with their children in the location. Field notes and interview transcripts are currently being analysed and key themes will be presented.

Translational outcomes:

Go-along interviews and working alongside service provider partners was a feasible and effective approach for ensuring the voice of parents experiencing hardship could be heard and included in research. This is vitally important to limit unintended consequences that may arise through implementation and research translation when equity considerations are not accounted for.

Future actions:

Lived experiences are needed to inform and develop place-based intervention strategies to create supportive environments that reduce children’s health and developmental vulnerability, and break cycles of deep and persistent disadvantage.

High value public health in a complex world requires a shift away from the reductionist lens. Current biomedically-driven interventions often overlook the upstream determinants of health, or at most emphasise one (biological, social, or environmental) factor at the expense of others. We propose that by considering the historical determinants – how we have evolved as a species via our interactions with the natural environment – we can reorient public health towards its fundamental intention of addressing the upstream ‘causes of the causes’.

Theoretical perspectives on health from evolutionary medicine, bioarchaeology, medical anthropology, and medical history are not typically considered to be within the usual scope of public health research and practice. We argue that these fields have tangible and pragmatic contributions to modern public health. For example, a 7000-year history of malaria is evident in the archaeological record of Southeast Asia, revealing patterns with prehistoric climate change of malarial endemicity in areas where these diseases are expected to become endemic in the next 30-50 years because of the climate crisis.

The translational potential of bringing the findings from evolutionary medicine research closer to public health has already been demonstrated. For example, we can model future tropical disease distribution (such as malaria) based on proxy indicators from the archaeological record. By studying historical climatic change together with bioarcheological findings, we can identify the past and likely future evolution of human diseases and their epidemiology.

Our approach provides a way to reorient public health towards its fundamental intentions by linking it more closely to the discipline of evolutionary medicine. By appreciating the historical determinants of health, we have a new lens through which the ‘causes of the causes’ and our relationship with the natural and built environment can be addressed and improved into the future.