Framework for the development of environmental health indicators.

Environmental health indicators provide information about scientifically-based linkages between environment and health. This information can be used for environmental health management and decision-making. Environmental health indicators are rendered more complex than either environmental indicators or health indicators because they must take account of factors such as the variability in susceptibility in individuals and variability in co-exposures. Such variability implies that any links that are defined may not apply to all individuals or groups at all times. Individual-level epidemiological studies can contribute to establishing environmental health relationships for particular places and time periods. However, cost-efficiency demands that aggregated data and known environment and health relationships be used to derive these indicators. Environmental health indicators can therefore be constructed by linking aggregated data, or by identifying environmental indicators with a health linkage, or health indicators with an environmental linkage. The framework for environmental health indicators proposed here is an adaptation of the Pressure-State-Response framework. Its first level consists of driving forces, which create pressures on the environment. These in turn alter the state of the environment by increasing existing exposures or introducing new ones, which produces a measurable health effect. In order to rectify the problem, actions (i.e., environmental health management) must be undertaken at each level. Thus the framework becomes the Driving-force--Pressure--State--Effects--Action (DPSEA).