**6. Public Involvement**

An important lesson learned in this Environmental Change and Health HPRU, and of relevance to all other public health research, is the value of involving communities and other stakeholders in the exploration and co-creation of the research. Minimally, this engagement will broaden the scope of the research inquiry to include perspectives of those who are directly affected by climate and other environmental change impacts. In addition to asking different questions and instilling greater creativity, such co-creation and involvement can make the research more directly impactful and applicable to the affected communities. Furthermore, involving communities would be highly beneficial to some areas of science traditionally perceived as "less suitable" for the involvement of communities, such as mathematical modelling. For instance, insights from the communities can be crucial to the model assumptions, formulation and critical scrutiny of model findings [120,121]. There are also direct benefits in terms of training and research support by these communities (Box 5).

Public participation frequently features in strategies for addressing inequalities and enabling communities to improve health outcomes [123]. It has also been argued that addressing complex interactions between natural environments and human behaviour requires a social learning approach which goes beyond the provision of information, public consultation and community participation, to the development of 'situated and collective engagement' [8,124]. This approach speaks to what Jasanoff [125] described as the development of 'civic epistemology', the collective evaluation of knowledge to inform public policy and social action.

Yet there are a number of barriers to effective public involvement in public health research such as the HPRU which can be difficult for individual researchers or small teams to address [126]. The competences needed for effective involvement by academics and other researchers are still rarely taught as part of the research curriculum [127]. Structural support for public involvement from universities, funders and public bodies (e.g., www.ecehh.org/about-us/engagement/; www.invo.org. uk/; the PHE People's Panel) can help address barriers, but if time and resources for involvement are not integrated into research programmes from the outset, it can be difficult for researchers to access this support. Better integration of public involvement in all our research into environmental change and human health remains both a challenge and an opportunity.

### **Box 5.** Health and Environment Public Engagement.

The Health and Environment Public Engagement (HEPE) group is a public forum of "critical friends" who have worked with the European Centre for the Environment and Human Health since 2013 (www.ecehh. org/about-us/engagement/; [122]). At quarterly meetings, HEPE discuss projects taking place in the Centre, including the HPRU in Environmental Change and Health research and support annual public workshops with researchers. These meetings use a range of participatory techniques to support inclusive and focused discussions.

The first workshop focused on prioritising issues the researchers focusing on possible salutogenic interactions with natural environments could address by linking large data sets. Researchers 'pitched' their ideas, and there was an initial individual vote by all workshop participants. Discussion of these choices was followed by a second vote which prioritised Mental Health and Social Relations. Notes from discussions showed some topics gained few votes because they were seen as integral to all the research rather than as individual projects (e.g., economic costs and benefits); this is a good example of why it is important to have multiple ways of recording workshop activities.

The second workshop used scenarios about individuals accessing natural environments. The group discussed whether this access made an important difference to the individuals and would any difference change their responses to self-reported health questionnaires widely used in the large secondary "big data" analysed by the HPRU team. The researchers were impressed by the magnified importance very small differences may have for people with multiple physical or mental health and social problems when answering these types of questionnaires.

The third workshop again used a scenario, this time alongside survey questions on partner/spouse relationships. Discussions explored which were most relevant as measures of social relations, and whether these could plausibly be used to help explore whether natural environments improve health directly, or whether this occurs through the promotion of better inter-personal relationships. The group members were concerned that some of the standard questions used in research in this area might introduce bias because of different cultural expectations and different interpretations of the survey questions. This insight helped the researchers to identify which data to use in the secondary data analyses for the HPRU research.

Involving the public has substantially helped to shape the European Centre's work within the HPRU. Having HEPE as a standing group has greatly facilitated that public involvement. Public interest in this HPRU research has also attracted five new members to HEPE, with several members participated in the most recent Annual Meeting of the HPRU in Environmental Change and Health, creating a cycle of mutual interest and support.

There is a growing variety of methods and approaches for working with communities in research collaboration. For example, one method which can directly involve communities and other stakeholders is the *ecosystems-enriched Drivers*, *Pressures*, *State*, *Exposure*, *Effects*, *Actions* or '*eDPSEEA*' model [128]. The *eDPSEEA* model can also help to populate and expand our understanding of a theoretical model of the research question which takes into account the health of both the environment and humans by integrating ecosystem services into the theoretical model, whereas the more traditional DPSEEA model has focused more on a unidirectional link between environment and human health. There are many other approaches which can engage communities and lead to improved co-creation of research and training, many of which emphasise the importance of trying to appreciate and understand the complex systems underlying interactions between human health, climate and other environmental change [17]. These are essential activities as we face a world in which human-driven actions, both intentional and unintentional, can have planetary impacts.
