**7. Discussion**

In this paper, we have provided a brief overview of the growing subject area of human health and well-being with reference not just to climate change, but to other broader patterns of environmental change. There is growing evidence that environmental change is both caused by and influences human behavior and the health and well-being of global populations. In particular, we identified the emerging knowledge gaps in this area which are the focus of research by the HPRU in Environmental Change and Health and others [6,7]. However, there was no intention to imply that this selection of topics encompasses the entire research area of environmental change and health; rather the ongoing HPRU research provides a range of examples to demonstrate the complexity and importance of this growing research area. In this paper, we have highlighted the research on various aspects of human health and well-being, environmental change and the 'natural environment', including both threats and opportunities that rural and managed urban natural spaces have for a range of health and well-being outcomes. A key focus of the research has been on how a true appreciation of the complex and multi-dimensional nature of environmental change and health requires a deep integration of research approaches and findings from often disparate perspectives (including active community involvement), in order to better inform the trade-offs needed at a public health policy level.

The experience of the UK with regards to the impacts on the health of both humans and the natural environment from climate and other environmental change is not unique. As noted above, it is important to broaden our view of the potential effects of climate and other environmental change to include phenomena taking place distant in time and/or space from the UK (i.e., a more planetary perspective). Furthermore, the research presented in this paper demonstrates that there are lessons to share and to learn from others, particularly with the most vulnerable populations likely to be affected by climate and other environmental change, such as the tropical developing world, island states, and the polar regions, as well as our more local communities.

If we compare the achievements reviewed in this paper with research agendas such as those promoted by the World Health Organization (WHO) and other international agencies, the task has only barely been outlined by work conducted so far [5,6,129–131]. The assessment of health risks attributable to climate and other environmental change has only just started, including some initial evaluation of indirect effects such as infectious diseases. However, more remains to be done in terms of the assessment of effectiveness and cost-effectiveness of health protection and promotion strategies and measures, the assessment of the health impacts of potential adaptation and mitigation measures, and the assessment of the likely financial costs necessary to protect public health from climate and other environmental changes.

The main research gaps can be categorized as outlined below. There is a need to undertake research to:


Recommendations for research highlighted by the WHO are relevant to public health services development: (1) evidence of interactions of climate and other environmental change with other health determinants and trends; (2) knowledge of the direct and indirect effects of climate and other environmental change; (3) evidence on the effectiveness of short-term interventions; (4) evidence of health impacts of policies in non-health sectors; and (5) general public health skills deployed to strengthening public health systems to address the health effects of climate and other environmental change [132]. The inclusion of environmental public health in mainstream public health services, with attendant capacity building of the service workforce, is likely required for development of a valid research evidence base in this area at the rapid rate at which it is needed [133].

In addition, in order to understand and follow the consequences of the complex interactions between human health and well-being and climate and other environmental change, it is important to have appropriate monitoring and data collecting systems in place. Environmental public health tracking at all levels (locally, nationally, regionally and globally) joined up through linkage of databases and standardized collection systems is an essential ingredient to pushing forward the science in this area [134]. A greater appreciation is required of the importance of big data involved in environment and human health collected by these environmental public health tracking systems [135]. The affected communities across the world require access to these data, while respecting issues of confidentiality, privacy and data governance [136]. Additionally, an important implication of both big data and the surveillance/monitoring systems is the need for new ways of thinking about and analyzing these data, learning from the experience of other scientific disciplines (such as oceanography or climate change modelling) in terms of improving modelling expertise over much broader time and spatial scales [135–137].

To gain an appropriate understanding of the impacts of wider environmental change on health, there is a need for a systematic attempt to assess the risks and benefits using a common framework. Addressing environmental change requires an inter-sectoral response—bridging health, environmental and industrial sectors. The need for risks from climate change to be assessed is mandated under the UK Climate Change Act (2008). A wider assessment of risks and benefits of broader environmental change and other factors is needed so that resources are appropriately allocated to adapting to our changing planetary environment [25].

**Author Contributions:** Conceptualization, Writing—review & editing, L.E.F., G.S.L., M.P.W., J.M., I.A., H.L.M., K.M., G.N., B.W.W., G.M., T.T., D.H., G.L.I., E.L.G., K.M.H., C.H., A.B. and R.D.-D.; Formal analysis, M.P.W., J.M., I.A., G.N. and G.L.I.; Investigation, L.E.F., M.P.W., J.M., I.A., K.M., G.N., B.W.W., G.L.I. and K.M.H.; Supervision, L.E.F., G.S.L., E.L.G., A.B. and R.D.-D.; Writing—original draft, L.E.F., G.S.L., M.P.W., J.M., I.A., H.L.M., K.M., G.N., G.M., T.T., D.H., G.L.I. and K.M.H.

**Funding:** The research was funded in part by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Environmental Change and Health at the London School of Hygiene and Tropical Medicine in partnership with Public Health England (PHE), and in collaboration with the University of Exeter, University College London, and the Met Office (HPRU-2012-10016); the UK Medical Research Council (MRC) and UK Natural Environment Research Council (NERC) for the MEDMI Project (MR/K019341/1, https: //www.data-mashup.org.uk); the Economic and Social Research Council (ESRC) Project (ES/P011489/1); and the NIHR Knowledge Mobilisation Research Fellowship for Maguire.

**Conflicts of Interest:** The authors declare no conflict of interest. The founding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, and in the decision to publish the results. The views expressed are those of the authors not necessarily those of the NHS, the NIHR, the Department of Health and Social Care or Public Health England.
