Children’s Environmental Health Indicators for Pacific Island Countries

Abstract

Healthy environments support the wellbeing of children and the environment thus play a cardinal role in the future of Pacific Island Countries (PICs). Children are more vulnerable and at risk to environmental hazards than adults because they breathe, drink, and eat much more relative to body weight, resulting in greater exposures in the different environments in which children find themselves every day. We examine the role that children’s environmental health indicators (CEHI) can play for PICs to highlight priorities and we prioritise actions to improve children’s environmental health and thus achieve their ‘Healthy Islands’ vision. We conducted a systematic search of relevant documented and publicly available Pacific Island Country information on children’s environmental health indicators using the general Internet, as well as databases such as PubMed, Google Scholar, relevant UN agencies, as well as regional databases. Information on CEHI was available—mainly in grey literature—but not specifically aimed at PICs. Likewise, similar observations were made for peer-reviewed literature. From this review, we compiled summaries and a framework to propose the requirements as well as provide a foundation for the development of CEHI for PICs. CEHI development for PICs should ideally be a multi-sectoral endeavour within each PIC as well as for the region. This can be achieved through public, private, and academic sector initiatives to draw in all sectors of government as well as the relevant UN agencies and regional PIC-representative organisations.

Full text

International Journal of
Environmental Research
and Public Health
Review
Children’s Environmental Health Indicators for
Pacific Island Countries
Claire Brereton 1ID , Amelia Turagabeci 2, Donald Wilson 2, Peter D. Sly 1and Paul Jagals 1, 2,*ID
1Children’s Health and Environment Programme, Centre for Children’s Health Research, University of
Queensland, Brisbane, QLD 4101, Australia; claire.brereton@uq.edu.au (C.B.); p.sly@uq.edu.au (P.D.S.)
2School of Public Health and Primary Care, Fiji National University, Suva, Fiji;
amelia.turagabeci@fnu.ac.fj (A.T.); donald.wilson@fnu.ac.fj (D.W.)
*Correspondence: p.jagals@uq.edu.au; Tel.: +61-7-3069-7203
Received: 27 May 2018; Accepted: 29 June 2018; Published: 3 July 2018


Abstract:
Healthy environments support the wellbeing of children and the environment thus play
a cardinal role in the future of Pacific Island Countries (PICs). Children are more vulnerable and
at risk to environmental hazards than adults because they breathe, drink, and eat much more
relative to body weight, resulting in greater exposures in the different environments in which
children find themselves every day. We examine the role that children’s environmental health
indicators (CEHI) can play for PICs to highlight priorities and we prioritise actions to improve
children’s environmental health and thus achieve their ‘Healthy Islands’ vision. We conducted
a systematic search of relevant documented and publicly available Pacific Island Country information
on children’s environmental health indicators using the general Internet, as well as databases such
as PubMed, Google Scholar, relevant UN agencies, as well as regional databases. Information on
CEHI was available—mainly in grey literature—but not specifically aimed at PICs. Likewise, similar
observations were made for peer-reviewed literature. From this review, we compiled summaries and
a framework to propose the requirements as well as provide a foundation for the development of
CEHI for PICs. CEHI development for PICs should ideally be a multi-sectoral endeavour within
each PIC as well as for the region. This can be achieved through public, private, and academic sector
initiatives to draw in all sectors of government as well as the relevant UN agencies and regional
PIC-representative organisations.
Keywords:
children’s environmental health indicators (CEHI); CEH; CEHI; EHI; Pacific Island
Countries (PICs); Healthy Islands
1. Introduction
Child-specific environmental health indicators are required to track progress on children’s health
because children are a vulnerable, valuable, and at-risk subset of the population [
1
]. The theme of
this review is the application of indicators for children’s environmental health in a particular setting,
namely Pacific Island Countries (PICs).
Children are much more vulnerable and at risk to environmental hazards than adults because they
breathe, drink, and eat much more than adults relative to body weight, resulting in greater exposure to
environmental hazards present in air, water, and food [
2
–
4
] that can occur in the different environments
in which children find themselves every day [5].
The World Health Organization (WHO) has developed children’s environmental health indicators
(CEHI) for physical injuries, insect-borne disease, diarrheal diseases, perinatal diseases, and respiratory
diseases [
6
] and provided implementation strategies with global partners to facilitate country-level
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Int. J. Environ. Res. Public Health 2018,15, 1403 2 of 15
uptake of these indicators across the WHO regions [
7
]. However, the uptake and implementation has
been incomplete [6].
Given the considerable economic, environmental, and social challenges the PICs and their children
face, questions can be asked about the extent to which CEHI have been developed and implemented
across the PICs.
2. Children’s Environmental Health in Pacific Island Countries
Children of Pacific Island Countries (PICs) are of the most vulnerable in the world. As small island
developing states (SIDS), PICs share the vulnerabilities of other SIDS but are also potentially more
vulnerable and are therefore at increased environmental health risks because their own constituents are
often very remote (populations of the same country spread over many distant islands), with little direct
links to nearby larger economy states, and they often rely on foreign aid for economic support [8].
Children have a particularly special status in the PICs [
9
], recognized perhaps some time before
the wider global realization of the vulnerabilities and risks as well as the value of children, as reflected
by the Global Initiative on Children’s Environmental Health Indicators, which was launched at the
World Summit on Sustainable development in September 2002 [
1
,
7
]. The 1995 Yanuca Declaration
implies that healthy islands support the health and wellbeing of children and the environment and
thus play a cardinal role in the future of PICs [
9
]. At the Eleventh Pacific Health Ministers Meeting
in Fiji, held in April 2015, the meeting reaffirmed the Healthy Islands vision. The Healthy Islands
concept, as articulated by the Yanuca Declaration, has five elements—all of which are of importance in
the context of children’s environmental health (CEH):
•Children are nurtured in body and mind;
•Environments invite learning and leisure;
•People work and age with dignity;
•Ecological balance is a source of pride; and
•The ocean is protected.
Holistically then, the Healthy Islands vision embraces the all-important role that environment
plays in supporting and protecting the health of people—especially the children—of the region.
The PICs naturally place strong emphasis on the role that sustainable environments play in their
health and wellbeing, prosperity, and protection [
9
]. However, small island developing states are
highly environmentally vulnerable, especially because of the effects of climate change, low economic
growth [
10
], and the local environmental impacts of activities such as forestry and mining [
11
].
The PICs, with their high birth rate and high proportion of young people [
12
], are very aware of the
need to protect and nurture their children.
CEH as a discipline has emerged over the last few decades because of our need to better
understand and manage an increasingly complex set of issues regarding child health, but, as such, it is
not yet widely considered, nor practised, in PICs.
CEH is based on a wide and encompassing context of ‘environment’, as it considers and informs
environmental and public health practitioners and decision-makers about how early life exposures
to environmental and social conditions (which can be detrimental and/or beneficial) influence the
health and development of children either positively or negatively. CEH practice applies a very
inclusive definitions of childhood (broader than the Sustainable Development Goal (SDG) definition of
childhood which includes ages 0–14 inclusive), in order to cover exposure of children to environmental
conditions during the ‘windows of vulnerability’ that occur during pregnancy, infancy, childhood,
and adolescence [
5
]. As such, CEH also includes maternal exposures to environmental conditions
prior to conception that may influence the health of children. These windows of vulnerability have
no counterpart in adult life. Exposures to harmful environmental influences during these sensitive
periods program the child’s body toward diseases that may not become diagnosed until much later in
life [2,4,5].

Int. J. Environ. Res. Public Health 2018,15, 1403 3 of 15
Whilst the broader practice and services of environmental health are aimed at managing all
aspects of environment that can be to the detriment/benefit of whole populations across all sectors
of society and government, a more specialist practice of CEH needs attention in order to manage
children’s unique vulnerabilities, risks, and value.
The environments in which children live, learn, play, and even work have a particular significance,
as children need protection during the times they spend in them. These environments include
the inter-uterine environment (for the duration of pregnancy), home (depending on age—ranging
from 70–100% of time), travel, care-giving, school, occupational, and neighbourhood—the latter
strongly associated with the built (design and layout of urban areas) and natural (green space)
environment [2,3,5,13–15].
Children are disproportionately exposed to adverse environmental conditions compared to adults.
In relation to body weight, children drink more water, eat more food, and breathe more air than adults.
Children’s metabolic pathways, especially in the first months after birth, are immature. Thus, if these
environmental components are not of acceptable quality, their abilities to fend off, metabolize, detoxify,
and excrete many environmental pathogens and toxins are less than those of adults. Additional
age-dependent characteristics such as their hand-to-mouth behaviour and the fact that they live and
play close to the ground further increase their environmental exposures. Children are less able than
adults to deal with adverse environmental hazards (e.g., disaster, changing climate) and often cannot
avoid exposures—making them more susceptible to injury [2–5,13,15,16].
With limited resources and many competing priorities, PICs may find it difficult to identify and
improve the key attributes of the environments in which their children and young people could
survive, thrive, and transform as envisaged by WHO and UNICEF [
17
,
18
]. Environmental health
indicators (EHIs) specifically focused on children over the stages of their development to adulthood
are a tool that can be used to enable PICs to improve their children’s environmental health through
measurement, monitoring, and targeted action [19].
CEHI for PICs must inform on the common but also on the unique environmental influences
(including risks) on children’s health in early life, whilst also considering social and economic
pressures. This implies the need for indicators directly associated with maternal exposures and
the various anthropogenic environments with their economic and social conditions in which children
live, learn, play, and work, all of which affect children’s health. This calls for very specific—perhaps
unique—indicators to guide decision-making about the health and environment of children in the
PICs. These indicators will lead us to understand the current and future status and risks and benefits
of environmental hazard and protection as well as the exposures of mother, infant, toddler, child,
and adolescent health in a fast-changing environment—thus reflecting environmental health effects
through all stages of childhood. This will enable us to plausibly forecast the future environmental,
social, and economic burden of disease [20].
CEHI for PICs must inform about a more complex and broader environmental context than
most other countries would have to consider—even more so than the traditional environmental
health risk factors often described for environmental and public heath practice [
19
]. This is
because children’s environments in PICs are substantially layered and complex. Their environments
are naturally changing over space and time; current-day environmental changes for PICs are
rapid and unprecedented because of (amongst others) demographic shifts to urbanisation, climate
change, rising oceans, local and imported pollution, development pressures, ageing infrastructure,
and
more [10,11,14,21,22]
. Among these shifting environments, CEHI for PICs must also inform about
multiple exposures at different life stages, which are also rapidly transforming because of demographic
shifts in communities and developing economies [
10
]. Lastly, CEHI must inform about the influences
of the environment on the human genome and epigenome [
5
], as these will have substantial impacts
on PICs via the longer-term burden of environmentally-related diseases.
CEHI that measure children’s unique windows of vulnerability should be developed and actioned.
A challenge of CEHI is that health effects of exposures during childhood may not be seen for many

Int. J. Environ. Res. Public Health 2018,15, 1403 4 of 15
years. Collection of data on these exposures is an investment for the future, enabling research into
linkages between maternal health and child health, complex cause-effect chains, and health outcomes
with long lead times.
This review—given the complexities highlighted above—explores the extent of indicator
development and operational uptake to inform about children’s wellbeing in the context of their
environments in Pacific Island Countries. While it does not propose new indicators, it reflects (with
appropriate examples) on the areas and potential for developing new and more targeted indicators to
address issues related to environment and child health in Pacific Island Countries.
3. Methodological Approach
We conducted a systematic search of relevant documented information using the general Internet,
as well as the databases of PubMed and Google Scholar and relevant UN agency databases, to find
publicly available Pacific Island Country information. We reviewed the available literature of the
three UN agencies that align closely with the concept of CEH—namely WHO, UNICEF, and UNEP.
We also investigated regional literature (compiled with or without UN agency support), for instance,
the Secretariat of the Pacific Community (SPC).
We first searched for existing CEHI, EHIs, initiatives, and reports specific to PICs and then
extended our search to global CEHI information.
We also reviewed the specific indicator frameworks that could reflect environmental causes,
exposures, and health effects that were suitable for use in PICs. Whilst there are several descriptions
of what CEHI could look like and what would be likely frameworks to present these [
6
,
19
,
23
,
24
],
we re-contextualised what these would mean for Pacific Island Countries that place special emphases
on child health and the environment [25].
We then selected contexts and environmental causes appropriate to expressing the relationship
between children (over the childhood to adolescent lifespan) and their environmental as well as
social conditions, their exposures and behaviours, and the likely health effects. We also explored the
practicality of indicator clusters, that should be considered for the development of an indicators suite.
4. General Findings
While most PICs deliver on a variety of environmental health services—aspects such as
housing/shelter, water, food, sanitation, and waste management services—we were unable to find
any monitoring or information systems that measure and report on the efficiency of delivering these
services. The lack of systems and/or the need to establish information sharing systems on content,
impact, and future direction of health and environment are noted in a substantial number of the
reviewed literature [2,14,26,27].
It follows that indicator frameworks for environmental health services could not be found.
More specifically, we were unable to find any CEHI specifically developed for one or more PICs.
Whilst there are a number of reports and initiatives that highlight the need for EHI and CEHI, the
detailed work of determining a set of CEHI for adoption and setting up a monitoring and measurement
framework has not been completed in PICs. This is understandable, as information systems are
essentially based on indicators and their measures.
We found a limited number of peer-reviewed reports of studies on environmental health indicators
through academic database searches. This may be because the development of environmental health
indicators is often led by governments or international organisations, which results in most documents
being published as grey literature. This lack of peer-reviewed literature has been noted by other
studies [23].
The PICs are not unique in this instance. A 2014 study [
28
] found that EHI initiatives were not
yet well established globally, especially in developing countries. There were very few operational
Environmental Health Indicator programmes either at national or regional scales and those that did
exist were mainly found to be for developed countries. The indicators included in the programmes

Int. J. Environ. Res. Public Health 2018,15, 1403 5 of 15
were limited both in terms of their position in the causal chain and in terms of their thematic scope.
The use of indicators was also limited by uncertainties in framing the exposure-response relationships
that they implied, and the consequent inability to translate the indicators into common measures of
impact, be it on the environment, exposure, or health side. In addition, there was no information on
the extent to which the indicators have been applied in decision-making. Most were exposure-side
indicators focused on sanitation, water, and air quality [28].
Within the PICs, the Healthy Islands monitoring framework [
27
] contains some health-side
indicators that are specific to children and also some optional ecological balance indicators related to
the framework.
Looking outside the PICs, we found just two recent studies that specifically proposed indicators for
CEH [
6
,
23
]. In terms of governance systems, we found one active operational children’s environmental
health monitoring system. This is produced by the Children’s Environmental Health Network
and contains data specific to the USA. It uses hazard, exposure, health effect, and intervention
indicators [
29
]. There are a number of regional and national environmental health monitoring systems
including the European Environment and Health Information System (ENHIS), the USA National
Environmental Public Health Tracking Network (NEPHTA), and Environmental Health Indicators
New Zealand (EHINZ) [
30
–
32
]. These systems contain some information specific to children, but they
are all for developed countries.
One further source of potential CEHI is the UN’s Global Sustainable Development Goals (SDGs).
These consist of 17 interrelated goals, supported by targets and indicators. Many are relevant to
children’s environmental health, but to make them CEHI-specific, country-level data collection for SDG
progress tracking would need to be disaggregated into subsets such as age, gender, and geographic
location. If collected, this information could contribute to country-level reporting to the UN [
33
],
as well as catalyse in-country CEHI development.
5. Childhood Vulnerabilities, Risks, and Values in the Context of Their Environments
It was clear from the review that indeed all population age groups are, to variable extents, subject
to exposures to environmental conditions. Where these conditions are hazardous, the health outcomes
will invariably be negative. This is the case globally and not just for PICs. The literature also shows,
however, that children require specific considerations for monitoring their environmental exposures.
This will require a specific set of indicators for children’s environmental health. The rationale is to
address specific child vulnerabilities, risks, and values across childhood development stages within
the context of the important environments, behaviours, hazards, exposures, and health outcomes,
rather than just disaggregating general environmental health data into age clusters [1,19].
Children’s particular vulnerabilities also increase their risk of adverse health outcomes.
Depending on the life stage of a child (i.e., in utero and during the first years of life), they do not have
the capacity to avoid environmental risks [
1
,
5
,
19
]. In the context of environmental health indicators,
children also have specific values. The longer-lasting public health investments in their health over
their life spans are substantial—a sick child will cost society more if they develop lasting morbidity
into adulthood [
4
]. From a social-economics perspective, child health outcomes associated with
environmental risk will be useful to model and forecast future economic burden of disease and
facilitate preparedness of the governance systems that have to deal with these outcomes. Children’s
environmental vulnerabilities also make them sensitive early warning indicators of environmental
health threats to populations [
1
,
19
]. Vulnerability and risk as well as value are key incentives for
developing and implementing child-specific environmental health indicators at the country level.
Their stages of development place children in specific environments that environmental health
practices in PICs do not adequately consider nor attend to. For instance, environmental health law
and governance in most PICs tend to focus on delivering on the issues that should mitigate on
the environmental hazard side—such as water, food, sanitation, environmental hygiene, and waste
management—with the understanding that this will have a positive influence on the health outcome

Int. J. Environ. Res. Public Health 2018,15, 1403 6 of 15
side. Such services often do not specifically consider the efficiency of their reach to influence and
protect child health.
To provide this specific context, Table 1summarises childhood development stages, the important
environments and the health risk posed by each environment, environmental behaviours, hazards
and exposures, as well as health outcomes. While there is information on child activities and
associated risks in home and other care environments, important factors such as choice, time spent
in these environments, governance, and responsibility for each of the child environments are not
addressed in literature, which is a serious gap in the knowledge required to develop suitable indicators.
We nevertheless—in Table 1—provide a very broad risk classification for the child environments based
on perceived risk posed by each environment, as well as the estimated time that children might spend
in each environment.

Int. J. Environ. Res. Public Health 2018,15, 1403 7 of 15
Table 1. Childhood environmental health risks by development stage.
Development Stage Child Health Risk Posed by Child Environment a,b,c
Environmental Behaviours Environmental Hazards and Exposures Health Outcomes
H T CCAH S O N
Pre-birth XXX XXX X X - XX
Maternal and paternal exposures
Poor nutrition, smoking, hazardous
chemical intakes, environmental stress
Foetal exposures, birth weight anomalies,
congenital abnormalities
Infancy Birth to 12 months XXX XXX X - - XXX Move in ‘floor’ zone, hand to
mouth behaviour
Poor indoor and outdoor air quality, poor
water and food quality and quantity,
cleaning products and pesticides, poor
sanitation and environmental hygiene,
stressed environments
Diarrhoea, parasitic diseases,
environmental enteropathy, malnutrition,
stunting, respiratory diseases,
neuro-developmental
abnormalities, poisoning
Toddler 1–3 years XXX XX X - - X
Above, plus increased mobility
and exploration, no
apprehension of danger
Pre-school Child 3–5 years XXX XX X - - XX
Above, plus increased exposure
to other children, people,
and wider environment
Respiratory diseases, malnutrition, weight
abnormalities, parasitic and vector-borne
diseases, reduced learning capabilities.
School-aged Child 5–12 years XX - - XX - X Increased learning, group
activities, peer pressure
Adolescent 12–19 years XX - - XX X XX
Increased sense of adventure,
peer pressure, increased
risk taking
All of the above plus occupational hazards
and exposures, increased UV exposure
Social and behavioural problems,
overweight, injuries
a
Legends. H: Home; T: Walk/travel away from home; CCAH: Child care away from home; S: School; O: Occupational; N: Neighbourhood.
b
Health risk considerations.
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Table1.Childhoodenvironmentalhealthrisksbydevelopmentstage.
Development
Stage
ChildHealthRiskPosedbyChildEnvironmenta,b,cEnvironmentalBehavioursEnvironmentalHazardsand
ExposuresHealthOutcomes
HTCCAHSON
Pre‐birthXXXXXXXX‐XXMaternalandpaternalexposures
Poornutrition,smoking,
hazardouschemicalintakes,
environmentalstress
Foetalexposures,birthweight
anomalies,congenital
abnormalities
InfancyBirthto
12monthsXXXXXXX‐‐XXXMovein‘floor’zone,handtomouth
behaviour
Poorindoorandoutdoorair
quality,poorwaterandfood
qualityandquantity,cleaning
productsandpesticides,poor
sanitationandenvironmental
hygiene,stressedenvironments
Diarrhoea,parasiticdiseases,
environmentalenteropathy,
malnutrition,stunting,respiratory
diseases,neuro‐developmental
abnormalities,poisoning
Toddler1–3
yearsXXXXXX‐‐XAbove,plusincreasedmobilityand
exploration,noapprehensionofdanger
Pre‐school
Child3–5yearsXXXXXX‐‐XXAbove,plusincreasedexposuretoother
children,people,andwiderenvironmentRespiratorydiseases,malnutrition,
weightabnormalities,parasiticand
vector‐bornediseases,reduced
learningcapabilities.
School‐aged
Child5–12
years
XX‐ ‐ XX‐ XIncreasedlearning,groupactivities,peer
pressure
Adolescent12–
19yearsXX‐ ‐ XXXXXIncreasedsenseofadventure,peer
pressure,increasedrisktaking
Alloftheaboveplus
occupationalhazardsand
exposures,increasedUV
exposure
Socialandbehaviouralproblems,
overweight,injuries
a.Legends.H:Home;T:Walk/travelawayfromhome;CCAH:Childcareawayfromhome;S:School;O:Occupational;N:Neighbourhood.bHealthrisk
considerations.Highriskofimpact;Riskofimpact;Lowerrisk;Nomonitorablerisk.cTimespentinenvironment.XXX:Upto100%oftime
spent;XX:Upto60%oftimespent;X:Upto30%oftimespent;‐:Notimeconsiderations.Compiledfrom[4,5,16,19,22,34,35].

High risk of
impact;
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Table1.Childhoodenvironmentalhealthrisksbydevelopmentstage.
Development
Stage
ChildHealthRiskPosedbyChildEnvironmenta,b,cEnvironmentalBehavioursEnvironmentalHazardsand
ExposuresHealthOutcomes
HTCCAHSON
Pre‐birthXXXXXXXX‐XXMaternalandpaternalexposures
Poornutrition,smoking,
hazardouschemicalintakes,
environmentalstress
Foetalexposures,birthweight
anomalies,congenital
abnormalities
InfancyBirthto
12monthsXXXXXXX‐‐XXXMovein‘floor’zone,handtomouth
behaviour
Poorindoorandoutdoorair
quality,poorwaterandfood
qualityandquantity,cleaning
productsandpesticides,poor
sanitationandenvironmental
hygiene,stressedenvironments
Diarrhoea,parasiticdiseases,
environmentalenteropathy,
malnutrition,stunting,respiratory
diseases,neuro‐developmental
abnormalities,poisoning
Toddler1–3
yearsXXXXXX‐‐XAbove,plusincreasedmobilityand
exploration,noapprehensionofdanger
Pre‐school
Child3–5yearsXXXXXX‐‐XXAbove,plusincreasedexposuretoother
children,people,andwiderenvironmentRespiratorydiseases,malnutrition,
weightabnormalities,parasiticand
vector‐bornediseases,reduced
learningcapabilities.
School‐aged
Child5–12
years
XX‐ ‐ XX‐ XIncreasedlearning,groupactivities,peer
pressure
Adolescent12–
19yearsXX‐ ‐ XXXXXIncreasedsenseofadventure,peer
pressure,increasedrisktaking
Alloftheaboveplus
occupationalhazardsand
exposures,increasedUV
exposure
Socialandbehaviouralproblems,
overweight,injuries
a.Legends.H:Home;T:Walk/travelawayfromhome;CCAH:Childcareawayfromhome;S:School;O:Occupational;N:Neighbourhood.bHealthrisk
considerations.Highriskofimpact;Riskofimpact;Lowerrisk;Nomonitorablerisk.cTimespentinenvironment.XXX:Upto100%oftime
spent;XX:Upto60%oftimespent;X:Upto30%oftimespent;‐:Notimeconsiderations.Compiledfrom[4,5,16,19,22,34,35].

Risk of impact;
Int.J.Environ.Res.PublicHealth2018,15,xFORPEERREVIEW 7of15
Table1.Childhoodenvironmentalhealthrisksbydevelopmentstage.
Development
Stage
ChildHealthRiskPosedbyChildEnvironmenta,b,cEnvironmentalBehavioursEnvironmentalHazardsand
ExposuresHealthOutcomes
HTCCAHSON
Pre‐birthXXXXXXXX‐XXMaternalandpaternalexposures
Poornutrition,smoking,
hazardouschemicalintakes,
environmentalstress
Foetalexposures,birthweight
anomalies,congenital
abnormalities
InfancyBirthto
12monthsXXXXXXX‐‐XXXMovein‘floor’zone,handtomouth
behaviour
Poorindoorandoutdoorair
quality,poorwaterandfood
qualityandquantity,cleaning
productsandpesticides,poor
sanitationandenvironmental
hygiene,stressedenvironments
Diarrhoea,parasiticdiseases,
environmentalenteropathy,
malnutrition,stunting,respiratory
diseases,neuro‐developmental
abnormalities,poisoning
Toddler1–3
yearsXXXXXX‐‐XAbove,plusincreasedmobilityand
exploration,noapprehensionofdanger
Pre‐school
Child3–5yearsXXXXXX‐‐XXAbove,plusincreasedexposuretoother
children,people,andwiderenvironmentRespiratorydiseases,malnutrition,
weightabnormalities,parasiticand
vector‐bornediseases,reduced
learningcapabilities.
School‐aged
Child5–12
years
XX‐ ‐ XX‐ XIncreasedlearning,groupactivities,peer
pressure
Adolescent12–
19yearsXX‐ ‐ XXXXXIncreasedsenseofadventure,peer
pressure,increasedrisktaking
Alloftheaboveplus
occupationalhazardsand
exposures,increasedUV
exposure
Socialandbehaviouralproblems,
overweight,injuries
a.Legends.H:Home;T:Walk/travelawayfromhome;CCAH:Childcareawayfromhome;S:School;O:Occupational;N:Neighbourhood.bHealthrisk
considerations.Highriskofimpact;Riskofimpact;Lowerrisk;Nomonitorablerisk.cTimespentinenvironment.XXX:Upto100%oftime
spent;XX:Upto60%oftimespent;X:Upto30%oftimespent;‐:Notimeconsiderations.Compiledfrom[4,5,16,19,22,34,35].

Lower risk;
Int.J.Environ.Res.PublicHealth2018,15,xFORPEERREVIEW 7of15
Table1.Childhoodenvironmentalhealthrisksbydevelopmentstage.
Development
Stage
ChildHealthRiskPosedbyChildEnvironmenta,b,cEnvironmentalBehavioursEnvironmentalHazardsand
ExposuresHealthOutcomes
HTCCAHSON
Pre‐birthXXXXXXXX‐XXMaternalandpaternalexposures
Poornutrition,smoking,
hazardouschemicalintakes,
environmentalstress
Foetalexposures,birthweight
anomalies,congenital
abnormalities
InfancyBirthto
12monthsXXXXXXX‐‐XXXMovein‘floor’zone,handtomouth
behaviour
Poorindoorandoutdoorair
quality,poorwaterandfood
qualityandquantity,cleaning
productsandpesticides,poor
sanitationandenvironmental
hygiene,stressedenvironments
Diarrhoea,parasiticdiseases,
environmentalenteropathy,
malnutrition,stunting,respiratory
diseases,neuro‐developmental
abnormalities,poisoning
Toddler1–3
yearsXXXXXX‐‐XAbove,plusincreasedmobilityand
exploration,noapprehensionofdanger
Pre‐school
Child3–5yearsXXXXXX‐‐XXAbove,plusincreasedexposuretoother
children,people,andwiderenvironmentRespiratorydiseases,malnutrition,
weightabnormalities,parasiticand
vector‐bornediseases,reduced
learningcapabilities.
School‐aged
Child5–12
years
XX‐ ‐ XX‐ XIncreasedlearning,groupactivities,peer
pressure
Adolescent12–
19yearsXX‐ ‐ XXXXXIncreasedsenseofadventure,peer
pressure,increasedrisktaking
Alloftheaboveplus
occupationalhazardsand
exposures,increasedUV
exposure
Socialandbehaviouralproblems,
overweight,injuries
a.Legends.H:Home;T:Walk/travelawayfromhome;CCAH:Childcareawayfromhome;S:School;O:Occupational;N:Neighbourhood.bHealthrisk
considerations.Highriskofimpact;Riskofimpact;Lowerrisk;Nomonitorablerisk.cTimespentinenvironment.XXX:Upto100%oftime
spent;XX:Upto60%oftimespent;X:Upto30%oftimespent;‐:Notimeconsiderations.Compiledfrom[4,5,16,19,22,34,35].

No monitorable risk.
c
Time spent in environment. XXX: Up to 100% of time spent; XX: Up to 60% of time spent; X: Up to 30% of time
spent; -: No time considerations. Compiled from [4,5,16,19,22,34,35].

Int. J. Environ. Res. Public Health 2018,15, 1403 8 of 15
6. Requirements for Children’s Environmental Health Indicators for PICs
Frameworks for understanding and practising environmental health have been under constant
review and application for many decades [
6
,
19
,
23
,
24
]—especially since the Earth Summit in Rio De
Janeiro in 1992. These frameworks—with some variations—mostly apply a cause, exposure, and health
effect model [
36
]. More recently, the concept of planetary health has been framed with a similar
approach, using causal drivers that exacerbate mostly socio-economic factors, leading to adverse
health effects [37].
We developed a simple but novel framework along these lines, consisting of distal (underlying)
drivers, the changes these drivers affect in the environments of children, the conditions and
commodities in these environments that will be affected, and how these conditions and commodities,
as well as behaviours, shape children’s exposures that will ultimately lead to adverse health outcomes.
This will provide a clear framework for community-level indicator development and will enhance
the incorporation of these indicators into environmental health information services. Table 2presents
a narrative summary of the framework organized as five indicator clusters.

Int. J. Environ. Res. Public Health 2018,15, 1403 9 of 15
Table 2.
Children’s environmental health indicator clusters, their indicators’ requirements, descriptions of indicator types, and broad examples of indicator measures.
Indicator Clusters and Requirements Indicator Type Examples of Measures
Underlying (distal) drivers—to more plausibly predict the local conditions
While CEHI packages will be developed for mostly local conditions, indicators of global and regional
environmental changes, economic development and social patterns are useful predictors of similar
local patterns. For instance, new developments in industry, agriculture and forestry are often
emulated locally but might not be suitably adapted for local conditions. Distal environmental change
indicators, usually dominated by changing climate and global pollution, will provide predictors for
local environmental change.
Economic, demographic,
environmental change.
Global GDP, foreign aid, demographic
distribution trends, global climate change,
regional environmental measures.
Environmental change—to determine the trends that will increase vulnerability and risk
Changes that the underlying drivers bring on in the local environment come from mainly the things
that we live by and the wastes and depletions that result—and all will affect child wellbeing. For PIC,
this also includes the real threat of natural disasters, which are occurring more frequently. Global
climate change is driving local weather patterns, more frequent disaster events and changes in the
oceans (rising sea levels) and reefs of the Pacific. Local patterns of consumption and need/ease of
travel (transport) force energy production, resource depletion (oceans and forests) and proliferation of
imported goods. This also lead to local waste generation and pollution of air, freshwater, ocean, food
and forests as well as increased proliferation and new habitats for insect vectors. New, seemingly
more efficient goods such as vehicles and fuels, are imported at increasing rates often without
consideration for the unintended impact they might have. A classic example is motorised
vehicles—these are all imported and invariably become local waste at some point, with little if any
means to remove or having available land to dispose of the wastes properly. Derelict vehicles become
hills of hollow waste—providing new habitats for insect disease vectors. Social drivers such as
demographic shifts (population growth, younger populations, urbanisation), cultures and behaviours
and education all contribute to local environmental change. While these are not unique to PIC, these
are more challenging (and to a large extent distal) in PIC because of vast distances between islands of
the same country, low levels of resources to mitigate against environmental change, and modes of
travel between the islands to make things work (governance). Rapid urbanisation leads to challenging
settlement conditions and neighbourhoods—loss of habitat often with a lack of green space - that do
not protect child health. Biodiversity loss is driven by economic development and land use changes
for agriculture and urban development. All of these changes have a direct influence over the
environmental conditions and environmental commodities that children are subject to, summarised in
the next section. If the changes are not adequately managed towards health protection, then the
conditions and commodities will lead to adverse exposures.
Natural Environmental condition,
education/culture/maternal
education, energy usage, insect
vector counts and habitats, condition
of the built environment,
urbanisation, air, water soil and food
pollution, waste management, the
use of chemicals such as fertilisers
and pesticides.
Disaster frequency/magnitude, local sea level
rise and loss of habitat, local ocean acidity, local
ambient and ocean temperatures, reef health,
biodiversity loss measures, fish stocks, marine
reserves, deforestation trends, land use changes
for urbanisation, industrial development
(tourism and mining) and agriculture.
Proxy for pollution measures—these can be
fossil fuel usage—both for locally generated and
imported energy, vehicle numbers
disaggregated by type and fuel.
Measures of proportion of land inhabited by
insect vectors, urbanisation and settlement
growth, contaminated land from
industrial activity.

Int. J. Environ. Res. Public Health 2018,15, 1403 10 of 15
Table 2. Cont.
Indicator Clusters and Requirements Indicator Type Examples of Measures
Environmental conditions and commodities that will indicate the environmental hazard areas
These are essentially the ‘Healthy Environments’ required to protect the health and wellbeing of
children. These conditions are measurable and include ventilated and adequately-serviced and safely
constructed buildings (with sanitation and waste disposal) for home, care away from home, school
and workplace, in hygienic environmental surroundings (in buildings and neighbourhoods)
preferably with ample green space. This will require accessible and available safe water and food.
Soils must be kept free of anthropogenically induced microbial pathogens, parasites and chemicals.
Such protected and serviced environments will also prevent vector proliferation and movements.
Society must transition to clean energy, reduce vehicle transport and properly maintain roads—this
will reduce air pollutants such as particles and gases. The proper use of vehicles and electric good will
reduce noise, heat, radiation as well as reduce risks of injuries. Properly maintained environments will
also reduce risks of residual mental stress on children—especially with the constant and unavoidable
risks of sudden changes in environment due to disaster, or longer term but clearly apparent stressors
such urbanisation, loss of habitat and rising oceans.
Housing and building quality.
Quality of domestic and outdoor
environments including green space,
availability and quality of water food
and sanitation. Hazard -reducing
services such as waste management
including imports and downstream
waste reduction. Use of household
chemicals and pesticides,
Vector distribution
Air quality measurements; children
living/learning/being cared for in
environments with clean fuel stoves/improved
biomass fuel stoves, and/or where at least one
adult smokes, measures of water quality and
availability for children’s
environments—drinking and play/bathing, no
access to basic sanitation/environmental
hygiene services, access to green space, indices
of households providing conditions for insect
borne disease transmission.
Child-specific behaviour factors to determine exposure and risk and predict impact
The extent to which adverse environmental conditions and commodities pose detriment to children
depend on the actual conditions, but is also driven by their unique behaviours. Properly managed
exposure-related behaviours of children and their carers will enhance the benefits of properly
maintained environments and reduce the risks and impacts of associated diseases. Age-related
behaviours of children that influence their exposures are summarised in Table 1above. Requirements
for sound and healthy environmental conditions and commodities will be determined primarily by
the child’s stage of development. For instance, crawlers and toddlers require clean lower-zone
domestic environments because they crawl, sit, stumble and mouth things with which they come in
contact. Children living in informal settlements have multiple exposures. In addition to general air
and water pollution, they may also spend time playing or scavenging in areas polluted by solid and
industrial wastes. Behaviour change might not be sufficient—as the economic condition of the
household will determine the exposure. Children living in close proximity to busy roads are exposed
not only to air and noise pollution but also to risk of death or traffic injury. Children living in slum
conditions have little choice but to interact with that particular set of environments. As children
become more mobile, they explore spaces accessible from the home. Green spaces therefore are
important for physical and cognitive development but might not be available for substantial numbers
of children. Whilst the level of nutritional exposure will in part be determined by the quality of
product they receive from their environment—it is also childhood eating patterns that largely
determine how optimal their nutritional exposure will be. This behaviour, in combination with
appropriate personal hygiene, depends much on parental knowledge and practices in raising the child
at home and elsewhere. At school, the education systems must ensure that sound nutritional as well as
environmental knowledge and practices are embedded in the child. Children often have to work out
of necessity—with the workplace often not adapted to the vulnerabilities and risk of a young person.
Parental/carer/child education,
child education, behaviours, child
activities. Proximity to inevitable
hazardous conditions i.e.,
underdeveloped neighbourhoods
and proximity to roads.
Behaviour-related exposures to wastes in
neighbourhood or through scavenging,
proximity to a busy road, parental/carer
education to appropriate school level; school
age children attending school, children
completing primary/secondary education,
children in the workforce

Int. J. Environ. Res. Public Health 2018,15, 1403 11 of 15
Table 2. Cont.
Indicator Clusters and Requirements Indicator Type Examples of Measures
Disease conditions and injuries to understand current impact and forecast future social, economic and environmental burden of disability
The major diseases that children risk contracting through adverse environmental conditions and
exposure behaviours are summarised in Table 1. In terms of data requirements, the PIC Health sectors
should have adequate primary data which can be translated to appropriate indicators and their
measures. In turn, a well thought through implementable Children’s Environmental Health Indicator
sets will point out gaps in the health data as well as provide the data that will be used to model the
future burdens of disease.
Maternal health/perinatal mortality,
child mortality and morbidity for
chronic and communicable disease,
child injury including poisonings
Mortality rates with causes disaggregated into
acute respiratory illness, diarrhoea, insect-borne
disease, NTDs, physical injuries, other. Chronic
disease prevalence including respiratory disease
and communicable disease prevalence including
acute respiratory illness, diarrhoea, NTDs
respiratory disease.
Incidence of physical injuries and poisonings
reported disaggregated by age band,
urban/rural/informal settlement
Compiled from [1,2,6,14,19,25,27,34,35,38].

Int. J. Environ. Res. Public Health 2018,15, 1403 12 of 15
7. Sectoral Origin of the Information
The data that will define the CEHI will have to come from many sectors in the PIC
society [11,39].
CEH is highly inter-disciplinary and cuts across paediatrics, epidemiology, occupational and
environmental toxicology and medicine [
23
,
27
], industrial hygiene, exposure science, engineering,
architecture, urban planning, social work, education, ecology, economics, and political science [
5
,
11
,
19
].
A comprehensive level of data will be needed to inform indicators—a requirement that is
already difficult for developed countries [
6
,
39
] and almost impossible for developing regions such
as small island developing states [
10
,
16
,
18
,
30
]. However, some data is already being collected
though monitoring and surveillance in the PICs by the various sectors. Global agencies such as
the WHO, UNDP, UNEP, and UNICEF support gathering of data by ministries responsible for health,
environment, economy, development and planning, local government, transport, tourism, mining,
energy, and more. Aid organisations, universities, industry, and commerce all collect data to some
extent. Global and regional data (e.g., satellite data), be it for collected for other purposes or available
from international organisations such as the Secretariat of the Pacific Community (SPC) and Secretariat
of the Pacific Regional Environment Programme (SPREP), can be used. A suitable set of CEHI, be
it for local or regional purposes, will drive the necessary collaboration to integrate much of this
data—useful as is, or redirected and repurposed,—and provide incentives for increased targeted
monitoring and surveillance.
8. Discussion
The key to a peaceful, prosperous, and sustainable world is healthy, safe, educated,
and empowered children and young people [
40
]. Children are especially vulnerable and at high
risk of environmental causes of adverse health effects. Children’s unique sensitivity to environmental
changes are in themselves valuable indicators, as it helps us better understand the current health risks.
At the same time, understanding what is happening to children in the context of environmental causes
of disease is not just about understanding the current burden of disease, but also the future burdens,
since many of the effects on children’s health are carried forward into adult life, thus adding additional
disease burden [1,4].
While these are sound arguments, it is noticeable that the implementation of CEHI by countries
globally has been slow, given that many countries have the means to make it possible for their children
to thrive. Many countries, including developing countries, however, often do not fully recognise the
support role that the environment can play in supporting sustainable development for the health
of women, children, and adolescents [
18
]; they might also not have the means. The PICs, with few
institutional, governmental, or philanthropic resources to help them, are some of the most vulnerable
countries in the world to rapidly changing environmental conditions, created by globally developed
world carbon emissions and by population growth, leading to rapid urbanisation and growth of
informal settlements and pressure on natural resources [37].
As countries develop economically, children’s environmental health can be expected to
improve [
41
]. However, without a strong environmental health information service, based on
a well-developed set of CEHI, a consequence of development can be greater inequalities in children’s
health as living conditions and health service coverage decrease in the poorest populations in
developing countries [
42
,
43
]. Therefore, it is of critical importance to measure both lead and
lag (environmental cause and health outcome) indicators in order to capture the past, current,
and predicted future of children’s environmental health in PICs. This will enable PICs to avoid
unintended health as well as other social and environmental consequences of economic development
or overseas development aid investments.
The PICs, in common with other countries, collect information that can form part of a set of CEHI.
The reality is that any relevant measurements have been incidental to other initiatives across many
different domains and sectors of PIC society and have not been integrated into proper information
systems. While children’s environmental health is an emerging discipline that aligns with, and can

Int. J. Environ. Res. Public Health 2018,15, 1403 13 of 15
also be a subset of, environmental health services in PICs, the development and use of a CEHI suite
will provide a strong impetus for intersectoral collaboration and will support decision-makers to
understand environmentally-related future burdens of disease.
Whilst we argue that a well-developed CEHI suite will track progress from the community
level up through to the higher-end of decision-making at government level and thus enhance the
targeting of economic, social, and environmental priorities, the development of a comprehensive set
of indicators will involve a complex process. Most importantly, the development, implementation,
and collection of indicators must be achievable and tailored to each country’s specific needs. To improve
the likelihood of inclusivity and success, methods such as systems thinking, participatory modelling,
and elicitation of expert opinion will have to be applied. Perceptions and opinions from all stakeholders
about environmental health problems in PICs must be captured. From this input, the priorities to
be addressed and the actions required to solve the problems can be determined. Following on,
development of the various levels of indicators will then be undertaken, enabling measurements of
progress and impact to inform decision-makers.
We do not prescribe nor suggest what the actual indicators should look like that emerge
from this complex process. Instead we propose the broad requirements to be considered for
developing indicators and their measures. CEHIs must be appropriate—for instance, indicators
that measure poverty, informal settlement populations, internal and external air quality in rural, urban,
and peri-urban contexts, ocean and forest health, and access to environmental health services are
universally important but must be tailored to PIC-specific circumstances and needs.
In terms of child vulnerabilities and risks in the context of CEHI, the sections in our framework
where indicators for these will be developed are the drivers, changes, conditions, and exposures. These
are the areas where the more active interventions towards mitigations are foreseen. The disease and
injury section will provide the value indicators, which will be used to track progress of interventions
towards, as well as forecast the future of, health and wellbeing outcomes for children.
Sustainability is the key to maintaining healthy, ecologically balanced environments to support the
health and wellbeing of PIC children. This is clearly recognised in the ‘Healthy Islands’ framework [
27
].
Adverse human impacts on natural systems have accelerated steeply since the 1950s and current
rates are deemed unsustainable. On the premise that the need for sustainability is self-evident to
protect the wellbeing of children, sustainability measures should be included across all information
gathering by the various sectors. Because of the sensitivities it addresses, CEHI for PICs will raise
awareness and ensure that the data collected through the use of CEHI can be modelled to forecast
future environmental health risks and impacts as well as support country-level reporting on the SDGs.
Finally, development and implementation of CEHI must in the first instance be driven at the
communities and local government level. A probable reason why there has been slow progress of
development and implementation for CEHI in PICs is failure to translate and integrate the many
excellent policy-level environmental health indicators proposed by support agencies to action at the
community services level. This review has again enabled us to revisit the requirements for children’s
environmental health indicators that are practical, multi-sectoral, and address the vulnerabilities, risks,
and value of children in the Pacific Island Countries.
9. Conclusions
This review has shown that whilst child-specific environmental health indicators are essential to
track progress of children’s health and wellbeing over their life span, these do not exist nor is it practised
in Pacific Island Countries. Children’s environmental health indicators will be essential for supporting
Pacific Island Countries to achieve their Healthy Islands vision of environments that nurture children
in body and mind. The two tables were designed to focus on the unique circumstances of vulnerability,
risks, and value of children for environmental health practices in Pacific Island Countries. They further
highlight why we must develop child-specific environmental health indicators.

Int. J. Environ. Res. Public Health 2018,15, 1403 14 of 15
We recommend that the setup and measurement of CEHI be implemented as a fundamental
integrated multisectoral activity for Pacific Island Countries. It will provide a tool for prioritising
global and local issues that influence children’s environmental health, as well as for focusing local
and global attention on their most pressing problems. The framework of indicator requirements and
examples of indicators we propose highlights the priorities and areas of multisectoral collaboration in
Pacific Island Countries to protect and improve children’s environmental health.
Author Contributions:
Conceptualization: P.J. and C.B.; Methodology: P.J. and C.B.; Writing—Original Draft
Preparation: P.J. and C.B.; Writing—Review and Editing: C.B., A.T., D.W., P.D.S., and P.J.
Funding: This research received no external funding.
Conflicts of Interest: The authors declare no conflict of interest.
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