SOLUTION: Mandala of Health in the Anthropocene | My Assignment Tutor

Health Promot J Austral. 2020;00:1–14. wileyonlinelibrary.com/journal/hpja | 1Received: 29 April 2020 | Revised: 3 October 2020 | Accepted: 13 October 2020DOI: 10.1002/hpja.434L O N G R E S E A R C H A R T I C L EApplying the Mandala of Health in the AnthropoceneGeorgia Langmaid1 | Rebecca Patrick1 | Jonathan Kingsley2 | Justin Lawson1This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution inany medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.© 2020 The Authors. Health Promotion Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of Australian Health PromotionAssociation1School of Health & Social Development,Deakin University, Burwood, Vic., Australia2Centre of Urban Transition, SwinburneUniversity of Technology, Swinburne PlaceWest, Hawthorn, Vic., AustraliaCorrespondenceGeorgia Langmaid, School of Health & SocialDevelopment, Deakin University, Burwood,Vic., Australia.Email: glangmaid@gmail.comFunding informationSchool of Health and Social Development,Deakin UniversityEditor: Jenni JuddAbstractIssue addressed: The Anthropocene is a new era in which human activity has beenthe dominant influence on climate and the environment. The negative impact humans have on the earth’s systems pose significant threats to human health. Healthpromotion is a discipline well placed to respond to planetary health challenges of theAnthropocene. The overarching aim of this paper is to describe the elements of 21stcentury socio-ecological health and apply them in a revised socio-ecological framework for health promotion.Methods: A qualitative description study design was employed to explore the significance of ecological and cultural determinants of health and review models in contemporary health promotion to inform the development of a revised Mandala of Health.Purposeful sampling was used to recruit ten experts from across Australia includingacademics and practitioners working at the nexus of health promotion, environmental management and sustainability. Data were analysed thematically, using deductiveand inductive methods.Results: A revised Mandala of Health could address existing gaps in health promotiontheory and practice. Ecological and cultural determinants of health were consideredessential components of health promotion that is often lacking in socio-ecologicalframeworks. Indigenous Knowledge Systems were considered immensely importantwhen addressing ecological and cultural determinants of health.Conclusions: A revised Mandala of Health could encourage development of contemporary health models, assisting health promotion to evolve with the health andenvironmental issues of the Anthropocene. This study highlights the need for moretheoretical development and empirical research regarding ecological and cultural determinants of health in a health promotion context.So what?: In the context of the Anthropocene, this study highlights the potential gapsin health promotion theory and practice in terms of the natural environment andhealth and emphasises the need of a paradigm shift to embed ecological and culturaldeterminants with other determinants of health.K E Y W O R D SAnthropocene, cultural determinants, ecological determinants, health promotion, Mandala ofHealth, planetary health2 | LANGMAID et AL.1 | INTRODUC TIONDuring the past half century, the physical and natural environment hasbeen dramatically altered at such a magnitude and speed that criticalecological boundaries have been exceeded.1-3 This pattern has createda new epoch called the ‘Anthropocene’.1 The Anthropocene is a geological phenomenon recognising the dramatic impact humans havemade on the earth’s systems.1,4 These systems are ecological determinants of health (EDoH), which include oxygen, water, food, materialsand other protective mechanisms of the ecosystem.5 These have beenrelatively stable for the past 11 000 years.1 However anthropocentricactivities are disrupting these systems through population growthand rapid urbanisation, economic growth and industrialisation.1,5 Thehuman subsystem is expanding at a rate which is disproportionate toother supporting ecosystems which have fixed boundaries.6 Theseboundaries (or thresholds) include climate change, biodiversity, ecotoxicity, ocean acidification and resource depletion.1 As a result, ecosystem services that provide fundamental pre-requisites for human healthbecome disrupted, fragmented and scarce, consequently declininghuman health ensues.4,7,8 Ecosystem services are the benefits peopleobtain from ecosystems. These include:● provisioning services (for example food, fresh water, fuel);● regulating services (including climate and disease regulation andwater purification);● cultural services (including spiritual, educational and recreational),and;● supporting services (for example soil formation andphotosynthesis).9This is a geological phenomenon recognising the dramatic impacthumans have made on the earth’s systems.1,4 It is due to both thescale and the rapidity of these changes that this era is arguably thegreatest public health threat in the 21st century.10Human health and wellbeing are inextricably linked to these environmental changes of the Anthropocene.4,6,10 The Lancet recognises the improved quality of health that comes with respecting theintegrity of natural systems and calls for improved understandingon planetary health.10 Planetary health seeks to understand and promote the safe planetary limits in which human civilisation can flourish.10 Numerous studies demonstrate that the natural environmentcan promote or harm health.11-13 There has been a growing numberof reviews about the associated positive physical, social and mental health benefits from engagement with nature.14,15 Conversely,environmental damage (such as air, water and noise pollution) canthreaten human health and wellbeing.16It is thought health promotion is well-suited to address thecomplex planetary health issues.4,17,18 Planetary health encompasses a range of disciplines as it recognises the interdependencies between human health and the planet’s life-sustainingsystems.10 Planetary health builds on the existing mandates thatguide the field of health promotion and represents a new chapterin its constant redefinition within public health. The transferablecompetencies and intersectoral nature that is embedded in healthpromotion, is a well-suited foundation to addressing complexhealth issues such as planetary health. Additionally, the HealthPromotion Journal of Australia has now clarified their intent to include EDoH which further emphasises the role of health promotion in the era of planetary health.19The constant re-definition of health promotion has been expanded to include planetary health which was reflected in April of2019 at the 23rd IUHPE World Conference on Health Promotion inRotorua (New Zealand). This fostered the space for health promotersaround the world to come together and discuss its theme: “Waiora:Promoting planetary health and sustainable development for all”.20Furthermore, “stable ecosystems” and “sustainable resources” areoutlined in the Ottawa Charter for Health Promotion as prerequisites for human health.21 These mandates demonstrate the reciprocal relationship between the natural environment and human healthand highlight the role health promotion has in addressing EDoH.There is an opportunity to improve the conceptual modelling of ourrelationship with the natural environment to better our progress inaddressing the health threats of the Anthropocene.A socio-ecological approach to health is required which recognises both the dynamic interplay between individual and environmental factors at different scales and the interaction between thesocial and EDoH.1. However, it has been argued that health promotion has been “ecologically blind”.1 The primary focus of healthpromotion has been on the social aspect of health which was encapsulated by the World Health Organisation (WHO) Commission of theSocial Determinants of Health in 2008.22 Research and experts proclaim that the health impacts of EDoH (ie key elements of the naturalenvironment) are as significant and comparable to those of socialdeterminants of health (SDoH).4-6,10 Thus, the goals of 21st centuryhealth promotion should predicate ecological equity and stable ecosystems, creating a pathway for transition from public to planetaryhealth.3,10 This requires an ecological analysis of health promotionmodels focusing on the interdependence of social and EDoH.Health promotion has also been criticised for being westerncentric, particularly for lacking emphasis on cultural determinantsof health (CDoH).4,23 For example, CDoH from an Aboriginal andTorres Strait Islander perspective acknowledges that strong connection to culture and land generates a stronger sense of self-identity,self-esteem and resilience.24 A core principle of health promotion isequity, however, it is usually within a dominant western paradigmwhere Indigenous Knowledge Systems (IKS) are often omitted fromconventional public health approaches.4,23 Therefore cultural determinants will be considered in the study as research shows thatthese determinants can provide invaluable insights into fostering thehealth of ecosystems and ensuring ecological sustainability.4,23,25-28The exploration of the intersection between health promotion and protecting the natural environment is a relatively emerging field of practice and research. For example, in 2011 a specialedition in Health Promotion Journal of Australia opened discussionabout the role of health promotion in addressing climate change. In2015, The Lancet recognised that integrated approaches necessitateLANGMAID et AL. | 3engagement with a number of stakeholders, specifically including ‘Indigenous peoples and local communities’ who can generatenew insights and knowledge in the field of planetary health.10 Atthe same time, the Intergovernmental science-policy Platform forBiodiversity and Ecosystem Services (IPBES) attempted to constructa framework that embeds the western-different knowledge systems (including IKS).29 Other studies over a similar timeframe haveexplored the correlation between Aboriginal connection to countryand wellbeing, and researchers have emphasised the need for healthpromotion to embrace IKS.5,25,30 However, there lacks investigationin an Australian health promotion context about how to practicallymerge CDoH into socio-ecological models that dominate contemporary health promotion theory and practice.Following a comparative review of health-related key socio-ecological models that have been developed across time (n = 12)(Table 1), the Mandala of Health31 was chosen to guide the study(Figure 1). This model is a longstanding and frequently used conceptual model published in 1986 in the field of public health and healthpromotion and popularised the focus on an ecological approach towellbeing.31 It displays a holistic system level understanding of theinterrelationships between the individual and its surrounding environments. Some authors have already critiqued this model, suggesting that having the human at the centre of the model does not trulycomprehend the true cycle of life.27,32 Instead the model needs tobe refined to incorporate more layers to demonstrate the differentperspective of nature. However, this critique has only done theoretically and not through research, so this study aims to address thisgap in literature.The conceptual model has been widely used in academia andpractice, thus has high levels of utility to guide research and action inthe field of health. However, to date no studies have been found thatassesses the applicability of the Mandala of Health in the context of21st century health promotion and how it resonates with contemporary health issues. This paper has two aims;1. To explore the perceptions of health promotion and sustainabilityexperts about the significance of key determinants of health, inparticular EDoH and CDoH, in 21st century Australian healthpromotion.2. To develop a revised Mandala of Health model which will provide an updated visual representation of the role of Australianhealth promotion in addressing contemporary health issues in theAnthropocene.Little has been done in Australia to gain insights from healthpromotion and EDoH experts and academics working in the field,so this will play a vital role in creating such a framework. Using keyinformant interviews, health and sustainability experts discussedhow they use and adapt models, such as the Mandala of Health, toaddress challenges of the Anthropocene. They were also asked fortheir critique and input in relation to the Mandala of Health whichinformed the creation of a revised framework.2 | METHODOLOGY2.1 | Design and sampleQualitative description guided the study design.41 This designwas chosen as it provides a rich description of the data from theviewpoint of the participants which is suitable for the study aim.42The study was conducted with approval from Deakin University,Faculty of Health, Human research ethics committee (ProjectNumber: HEAG-H 46_2019).The lead author conducted a comprehensive review, comparisonand critique of available socio-ecological models prior to startingdata collection (Figure 2).The relevance of the identified models to health promotion, themodel’s strengths and limitations in relation to planetary health andmore specifically ecological and cultural determinants were compared(outlined in Table 1). Furthermore, the research team consulted with alead author of the Mandala of Health as part of the decision-makingprocess. After much deliberation, the Mandala of Health was chosento guide the study. It is holistic in nature with clear boundaries makingit easy to identify the interactions between determinants.43The study employed a purposeful sampling strategy, in particular convenience sampling.44 This sampling technique is valuable forcapturing and describing a diverse range of perspectives that haveemerged from adapting to different conditions.44 Convenience sampling was deemed most appropriate due to time restraints whereaccess and easy collection was necessary.45 Eligibility criteria forparticipation were applied to enhance credibility.45 The criteria forinclusion limited participants to: people with experience or qualifications with working at the nexus of health promotion and environmental management/sustainability; are currently employed asan academic or practitioner in Australia; are working from culturallyand geographically diverse parts of Australia; and were suitable forinclusion in a low-risk human research ethics approved project. Thiswas established by their publicly available profiles.Ten health experts (n = 5 Female; n = 5 Male) were recruitedin the study including seven academics and three practitioners.Gender equity is a guiding principle of the authors research field,thus guided the approach to sampling.46 The sample was limited to10 participants as this study was intended for rich data and a deeperinvestigation which provides a snapshot for further research. Theseparticipants were identified from the chief investigators existinglist of extensive national and international networks working in thenexus of health promotion and/or planetary health. Invitations tookplace via email and once individuals responded, they were sent aPlain Language Statement (PLS) and a Consent Form.The lead author undertook all interviews. This had the benefit ofminimising the risk of perceived bias from pre-existing relationships(as the lead author did not have the existing relationships, the seniorauthors did). Furthermore, the PLS clearly states participants’ withdrawal rights as well as a statement outlining that the decision to participate will not affect any relationship the participant may have with4 | LANGMAID et AL.TA B L E 1 Socio-ecological frameworksModel Description Strengths/limitationsEcological model33 Displays a dynamic equilibrium between host,environment and agent.• Displays health as interconnected andbalanced with the environment.• Assumes that all exposed individuals thatbecome infected do not correspond withcurrent patterns of ill-health; as manydiseases are non-infectious or a diseasemay have multiple causes.The Wellness Model34 Portrays health along a continuum with no end-state.Although not explicitly in the model, other influencingfactors to health are identified such as stressmanagement, nutrition and physical activity.• Derives the concept that wellness can beachieved no matter the current state ofphysical health. Mere absence of illnessdoes not bring wellness nor quality of life.• Lacks focus on biophysical environmentsand socioeconomic influences thusincomplete as an ecological model.Community Ecosystem Model35 A community-orientated model that integratescommunity health and sustainable development.• Six qualities could be used as indicators ofa healthy community ecosystem.• Narrow focus on what constitutes healthat a community level in the form of threecircles.Biopsychosocial Model of Health36 Emphasises the interdependence between psychologicaldispositions, biological processes and social behaviourin the context of health and illness.• Boundaries are less rigid, and connectionshave been made between disciplines.• No consideration of the natural orbiophysical environmental determinants ofhealth.Bronfenbrenner – Ecology ofHuman Development37Interactions are displayed between the individual (centre)and environments at different levels; micro-, meso-, exoand macrosystem.• Provides a holistic, environmental influenceon health.• Anthropocentric view of health andwellbeing.Ecological Model for HealthPromotion38Patterned behaviour is the outcome of interest with fivelevels of influence.• Guides the conceptualisation of a specificproblem and identifies where interventionsare appropriate.• No mention of the natural environment.Ottawa Charter21 Identifies prerequisites for health including “stableecosystems” and importance of advocate, enable andmediate as action areas.• Focuses on both individual and structuralinfluences on health and wellbeing ratherthan disease.• Cursory reference to biophysicalenvironmental factors.The Health Map 55 Depicts overarching influence of the global ecosystemon human health or ‘habitat’. Different facets of humanlife are reflected in spheres that move through social,economic and environmental categories.• Explicitly recognises climate stability andbiodiversity as essential components of theglobal ecosystem.• Individual is the centrepiece of the map–limited recognition of the influence oflarger spheres on health.The Butterfly Model of Health39 Capacity of achieving health is dependent on the balancebetween socioeconomic and biophysical environmentalpressures. These are influenced by each other throughthe actions of individuals.• Broken line suggests how naturaland human influences move betweenecosystems.• Egocentric view – places humans at thecentre of the ecosystem.Transformation via BalancedExchanges Model (T-BE)40Presents the exchanges between human and naturalsystems within the built and natural environment.Outcome of these exchanges is human health.• Human and natural environment arecoupled together with neither takingprecedence.• Built environment could be clarified withrespect to systems such as transportation,mining and agriculture.(Continues)LANGMAID et AL. | 5the research team. A future research direction can build from this initial convenience sample and instead identify experts in socio-ecological health and health promotion to gather further and broader input.2.2 | Data collection and analysisIndividual semi-structured interviews were conducted either face-toface at the participants’ workplace (n = 3) and via video (n = 5) or phonecall (n = 2). Interviews are the most common form of data collectionin a qualitative description study.45 Semi-structured interviews wereused as they offer participants the opportunity to explore the issuesthey feel are important, creating a diverse range of data.47 One interview per participant was audio-recorded, with an average duration of30-60 minutes. After questions about demographics, a predeterminedsemi-structured set of questions was followed which included investigating the value participants placed on CDoH and EDoH in researchand practice, and what future strategies or priorities they believedwere essential for health promotion to adapt to future health issues.The audio recorded interviews were transcribed verbatim by thelead author. During transcription of the data all original names werereplaced by pseudonyms and information was coded. Data wereModel Description Strengths/limitations“Our Wellbeing” A holistic modelof Indigenous Wellbeing30Focuses on the interrelated nature of wellbeing and theenvironment.• Background images acknowledge theconflict Aboriginal people find themselvesin when living in an urbanised settingwhilst still wanting to connect to Country.• Lacks detail on the biophysicalenvironment.Exploratory Framework forAboriginal Victorian People’sWellbeing30Provides visual understanding of Aboriginal peoples’connection to/interaction with Country. Includes bothWestern and Aboriginal determinants that impact onwellbeing.• Reflects holistic nature of health andwellbeing including a wide variety ofdeterminants.• Does not provide solutions to how bothwestern and traditional views can benefitfrom one another. No reference to waterand animals in the model.TA B L E 1 (Continued)F I G U R E 1 Mandala of Health246 | LANGMAID et AL.therefore re-identifiable. A copy of the interview transcript was sentto participants to ensure accuracy and transparency prior to dataanalysis.42 Participants were provided an opportunity to clarify oradd further data they may deem important or valuable.Transcriptions were coded thematically using NVivo (version12); data analysis software. In keeping with qualitative descriptionapproach, thematic analysis techniques were used to stay close tothe data.41 Thematic analysis provides a rich, detailed and complexaccount of data that are qualitative in nature.48Analysis followed an iterative, inductive and deductive process.Initially, codes were inductively derived from the data then categorised into themes prior to any interpretation.49 Once complete, thetranscript was re-read alongside the final list of themes to make surecodes were not taken out of context and analysis stayed close to thedata.50 Low inference was then used to analyse these themes andconsider them in relation to the literature.51Finally, a deductive process was used to develop a revised modelof the Mandala of Health.50 Themes that referred to participants’perspectives about ecological models, including the Mandala ofHealth, were collated. Using a deductive process, necessary changesto the original Mandala of Health were made that reflected thesecategorised themes and summarised participants’ perspectives.To ensure rigour, the researchers implemented several strategiesincluding; investigator triangulation during data analysis to obtaindescriptive validity and ensuring accuracy and credibility52; and reflexivity where authors actively engaged in critical self-reflectionwhen analysing and discussing findings. This ensured findings represented the views and perspectives of the participant and were notbe affected by researcher bias.53Second, interpretative validity was achieved through participant member checking of the interview transcripts, key findings from the analysis and revised conceptual Mandala of Healthmodel.49,51 Interview transcripts were emailed to participants aswell as an opportunity to provide any feedback on the revisedMandala of Health model (five participants provided furtherfeedback).3 | RESULTSThe central finding was that CDoH and EDoH are fundamental determinants of health and essential components of health promotion theory and practice, however they both lack attention. Thissection unpacks these key findings in relation to four themes:F I G U R E 2 Literature review strategyLANGMAID et AL. | 7● CDoH: the cultural context of communities and gaining furtherunderstanding of Indigenous cultures are crucial elements ofhealth promotion.● EDoH: these determinants require more attention in the field ofhealth promotion, there is a lack of understanding about the linkbetween environment and health.● Conceptual models/ theoretical perspectives: participants gaveexamples of what they believed were useful and relevant socioecological conceptual models other than the Mandala of Health.● The Mandala of Health: includes participants’ feedback when discussing the applicability and relevance of this model in today’ssociety. A revised model was created in response to this feedback(Figure 2).3.1 | Cultural determinants of healthCDoH were described as a major influencing factor on how humansperceive the environment and the connection they have to nature.This was emphasised by one participant stating:“If you look at what it is that’s driving ecologicalchange, it fundamentally has to do with our culturalvalues.” (P10)Participants believed culture is very context specific, so communityconsultation is essential to identify the cultural determinants of healthof a particular population group for it then to be integrated into healthpromotion. When discussing CDoH, participants discussed the tendency of a western culture to view nature as separate, subserving andinferior to the human world. Participants labelled western society having “topophylic, not biophilic” (P5) connections to places. The perceivedlack of understanding that western cultures have about the interdependent relationship between the natural and human world was contrasted to IKS. This was highlighted by one participant acknowledging:“They [Indigenous cultures] have a kind of understanding that you don’t take more than what youneed from their environment. We just do not havethat.” (P5)Participants mentioned that health promotion in both theory andpractice need to engage with other cultures, learning from TraditionalOwners of the land and incorporate IKS into contemporary way ofliving. Language was listed as an inhibiting factor in understandingother cultures and to having a connection to nature. Language throughspeech, stories and dance is just as valuable as empirical evidencewhich “we’re only just now coming to grips with.” (P1).3.2 | Ecological determinants of healthIt was suggested by participants that EDoH has been a neglectedpart of health promotion due to a lack of understanding amonghealth professionals about EDoH compared to other determinantsof health. The term “ecologically blind” was used by several participants, suggesting that health promotion’s explicit focus on SDoH ashindered the role of EDoH. One participant articulated that:“Since the 1980s we’ve been pushing a social determinants agenda and that to the detriment of ecologicaldeterminants. Now it’s time to stop being ecologicallyblind and bring it back into the picture.” (P5)Participants thought EDoH need explaining and portrayed in a way thatis easily understood and that is related to human health. Furthermore,it is essential to have SDoH and EDoH connected and not separate toaid the lack of understanding among health experts and the public. Asexplained by one participant:“I think that is a more contemporary way to look at it– meshing the social determinants with the ecologicaldeterminants. So that people can kind of get it a bitbetter.” (P5)Participants’ responses questioned the principles of health promotionthrough their varying levels of frustration about the lack of leadership,urgency and action around EDoH. Participants felt that there was alack of understanding of the non-linear relationships between the environment and health in health promotion. Climate change was usedas an example to demonstrate this. One participant’s remark was that:“Australia lags behind comparable countries whenit comes to tackling the health impacts of climatechange.” (P2)This discussion linked back to CDoH as it was explained how ill-healthcan be prescribed to the way that humans are impacting the natural environment. This refers to the lack of respect and connectionto nature can cause repercussions for human health. For example,participants believed literature on climate change and EDoH is climate-science focused with little attention to human health and wellbeing, which further distances people from the environment. As astrategy to overcome this, it was suggested to focus on the effectsthat the characteristics of the Anthropocene has upon human health.Participants suggested focusing on the effects of human healthrather than the health of ecosystems as this is more easily understood by many people. If human health is perceived to be underthreat, it creates a sense of urgency and action towards mitigatingthese environmental problems.3.3 | Conceptual models/theoretical perspectivesOverall, there was consensus among participants that conceptualmodels are a useful tool for communication and encouraging interdisciplinary work. However, due to the complexity of health promotion, participants found it difficult for one model to demonstrate the8 | LANGMAID et AL.many nested systems of ecosystems, thus conceptual health modelsare more useful as a guide.Models that were used by participants included the DonutModel by Raworth6 which integrates both social and ecological determinants, emphasising ecological boundaries. It was described asa “modern comparator” (P10) to the Mandala of Health. In addition,The Health Map by Barton and Grant54 was believed to be a goodexample of clearly demonstrating the interface of the natural andbuild environment, including EDoH, within a global ecological system. In summary, it appears that there are other helpful models ofhealth beyond the Mandala of Health (for example Sallis’ EcologicalModel of Active Living55). However, this model was not included asit is purely a behavioural model with a focus on physical activity. Theother models are encapsulating the relationships between humansand environment through a variety of mechanisms. Thus, this paperhas a focus on relationships of human environments as opposed tothe behaviours of humans to environments.3.4 | The mandala of healthApart from one participant, all other participants were familiarwith the Mandala of Health and all were able to provide critical andconstructive feedback on its design, applicability and development.The “body, mind and spirit” was the most praised aspect of the modelas well as the “onion ring” format which demonstrates the non-linear relationships among the determinants of health. However, theyfound it so fully encompassing and broad that it was difficult to applyto a specific situation.In response to participant critiques and suggested revisions synthesised with previous review of literature, this study developed arevised model of the Mandala of Health (Figure 3).The following section demonstrates participants interpretationsof the Mandala of Health and subsequently recommendations forrevision. Table 2 further clarifies how each enhancement of theRevised Mandala of Health was informed by participant responsesand empirical literature.The revised model’s shared core of both human health andthe health of natural ecosystems demonstrates the close interrelationship between them as compared to the original Mandala ofHealth model. Participants believed that the interactive nature ofsystems was missing in the original model, hence the authors usedbroken lines, as used in the Butterfly Model39 to demonstrate this.Participants thought it would be beneficial to embed EDoH andSDoH to emphasise the equal importance of and the interconnection between these two fundamental determinants of health. EDoHF I G U R E 3 Revised Mandala of HealthLANGMAID et AL. | 9TA B L E 2 Characteristics, participants perceptions and supporting literature focused on the Mandala of HealthCharacteristic of revised modelParticipants perceptions of the originalMandala of Health Supporting literatureShared core of natural environment andhuman health, representing the codependent relationship between thesetwo components.“this model has a weakness in the sense thatit’s got a person in the middle” (P7)Buse et al4• Intersection of human health and environmentalchange and the interdependence between these isan emerging development in the field of health.• Human health and civilisation have flourished at theexpense and degradation of nature’s life supportsystems. These natural systems are commonlyperceived as separate to society and predominantlyhas a materialistic benefit to human civilisation.The broken lines throughout the modeldemonstrate the non-linear relationshipsbetween all systems.“the interactive nature of the systems thatwe’re trying to deal with… seems to be missingfrom this.” (P7)VanLeeuwen et al33• There is a need to fully understand the complexinterdependencies of human wellbeing andplanetary health. Similar to the ButterflyModel39, the broken lines signify the profoundinterdependencies and permeability between allenvironments and systems, in which humans act asintermediaries between.Explicitly labels EDoH and SDoH of healthequally.“the last thing you want to do is have theecological determinants here and the socialdeterminants here and not talk. Not engagethem.” (P3)Raworth6Jackson57• Human health and existence depend upon healthynatural ecosystems and the interdependenciescomprising these systems.• There is a need to lead the integration of SDoH(that focus on equity and current populations) withthe EDoH.Embeds IKS as a cultural determinant ofhealth to encourage engagement with thewider community“the two paradigms are quite difficult toreconcile at times.” (P2)“we have a lot to learn from Indigenouscultures” (P3)Ife & Tesoriero58Kingsley et al25• Indigenous knowledge & perspectivesdemonstrate ongoing development in leadershipand governance for EDoH in relation to otherdeterminants of health – however are oftenover-looked.• To effectively tackle issues, there must be aunified collaboration and understanding ofconcepts and ideas with communities, policymakers, practitioners and academics.The term family changed to ‘socialconnections/relationship’ as it wasconsidered too narrow for contemporarysociety.“I would probably make that change to familyand friends…the social relationships.” (P9)“well I think in the 21st century, there’s a rangeof questions to ask for what is family? How doyou define family?” (P2)• The nuclear ‘family’ structure is not a naturaloutcome for Indigenous Australians and theirkinship systems.• Many other ethnic communities in Australiadiverge in their family structure from the typesenvisaged from present models.Culture and community are on the samelevel and closer to the individual“I think we know that culture is deeplyconnected to an individual’s experience inlife and impacts and relates to health andwellbeing…an alternative framework wouldsee that more closely connected to theindividual, but their culture obviously appliescross society” (P2)Weir23• Culture is a large determining factor on all aspectsof health. Those from varying cultures view thingsvery differently, therefore it lies at the core of theindividual’s health.Top half is representing human systems,bottom half natural systems which is apraised feature of the original model.Adds in more detail of ecologicalboundaries (ie the biophysicalenvironment).“above the line you have essentially the socialsciences, below the line you have the naturalsciences. The whole model integrates thenatural and social sciences which is what wehave to do.” (P10)Hancock et al1● Literature identifies planetary boundaries (ie thebiological and physical processes and systems whichmaintain Earth’s essential systems) play a crucial rolein allowing humans to grow and flourish.● Human wellbeing depends on finding the balanceof addressing health and wellbeing issues withinthe limits of the planetary boundaries. Cannotachieve one without the other.(Continues)10 | LANGMAID et AL.include the life-giving resources and processes of the natural environment, including but not limited to clean air, fertile soils, freshwater, marine aquatic systems, plants and animals. The term family was changed in the revised model as the definition of family hasevolved to reflect anthropological approach to kinship which is notinclusive of other cultures. For example, a nuclear family structure isnot a “natural” outcome for Indigenous kinship systems.59In the revised model, culture has moved from the outer ring tobecome closer to the individual as it is believed culture has equalinfluence as community has upon an individual’s health and wellbeing. “Human-made environment” as seen in the original modelwas found to be mis-leading as it was believed that humans ultimately influence everything, including natural environments, sotherefore every environment was “human-made” as believed byparticipants.Similar to any two-dimensional model, it cannot portray thecomplexity of these interactions in their temporal and spatialdomains. In particular, the relationships between elements ofCharacteristic of revised modelParticipants perceptions of the originalMandala of Health Supporting literatureIncludes policy and governance thatinfluences every system“I can’t see policy. So much of policy can haveflow on effect to the individual.” (P3)Patrick et al5World Health Organisation21● Health promotion practitioners need to beencouraged to involve policy makers across arange of sectors to advocate for positive policyreform (in regard to climate and health).● There is a lack of policy discussion and actionregarding EDoH (compared to the SDoH).● One of the five action areas of the OttawaCharter21 is ‘building healthy public policy’meaning health is on the agenda of policy makerswho must be aware of health consequences oftheir decisions.Lifestyle fully encompasses personalbehaviour, activities and work“the framework doesn’t represent the extentto which personal behaviour is impacted byother societal forces.” (P2)● Personal behaviour is one of the main SDoH.● Employment and work conditions heavily impacthealth and health equity.The term ‘sick-care system’ changed to‘health prevention services’ to be moreinclusive of preventative healthcare/health promotion.“If this is to be used for the purposes of healthpromotion, it would be good to highlight thethings that actually contribute to that…whatare the facilitators of it.” (P2)Patrick et al18• Health promotion has an important role to playin responding to and engaging with emergingclimate-health related issues.Time and geographical scales endeavoursto demonstrate the multi-dimensionaland multi-level spheres of health andthe complex interactions between thedeterminants of health.“it’s not just to be about the individual…it’s onmany levels and scales as well.” (P5)“you’ve got such a diverse multi-scale focus ofspatial, temporal, time lagged processes etc”(P8)Millennium Ecosystem Assessment9Prescott et al3● The direct and indirect impacts on human healthand the health of the natural environment can takeplace at more than one scale and across differenttime scales – as seen in the MEA ConceptualFramework.● There are formidable challenges to health at allscales (person, public and planetary) and vigilancetowards the upstream barriers to health is animportant factor.‘Human-made environment’ changedto ‘built environment’ to differentiatethe built environment to the naturalenvironment, as it was unclear of whatconstituted ‘human-made’ environmentsin the original Mandala of Health.“I just don’t understand why human-madeenvironment is so prominent. Becauseultimately humans influence everything. Toseparate out human-made environmentsfrom the environment as a whole…is not thatuseful.” (P1)Hancock et al1● The formalisation of the Anthropocene wasinfluenced by the acceleration of the humanimprint on Earth’s systems, thereby evidentlysuggesting human activity shapes and influencesevery type of environment.Addition of natural environmentpurposefully placed closer to theindividual to capture the intimaterelationship between them.The following quote describes the idea of‘biosphere’ as seen in the original model:“It’s all a construct of human aspects andthere’s just this ring around the outside thatsays environment or biosphere and it neversort of fully expressed that reciprocity orthe fact that it’s not just a vague undefinedsomeone else’s business settings for all humanactivity.” (P8)Steffen et al2● Literature identify major gaps in understanding thelinks between environment and health and also theeffects of interventions that reduce environmentalchange and protect human health. Placing thenatural environment closer to the individualemphasises the need to make the link between thetwo.TA B L E 2 (Continued)LANGMAID et AL. | 11the figure do not fully capture the complex interactions that canoccur among them. The revised model with time and geographical scales, endeavours to demonstrate the multi-dimensional andmulti-level spheres.4 | DISCUSSIONThe purpose of the study was to explore the application and relevance of conceptual socio-ecological health models, such as theMandala of Health, in guiding and facilitating dialogue to addressthe challenges of the Anthropocene for contemporary health promotion practice. Two of the key findings were the lack of attention toEDoH in health models as well as health promotion being criticisedfor being anthropocentric; that is the perspective that views humanity as the centre and core focus.56This study highlights the lack of both leadership and action regarding EDoH in the field of health promotion. Leadership is oneof the five action areas for health promotion capacity building.60,61Capacity building allows health promotion to evolve and enhanceits ability to address the underlying determinants of health.60 In thecontext of the Anthropocene and the rapid ecological changes happening to the environment, capacity building is essential for healthpromotion to adapt and mitigate against the underlying causesof these environmental and health challenges that face the 21stcentury.4The lack of emphasis on EDoH compared to other determinantsof health in health promotion as outlined by study participants issupported by literature.1,62 The Ecological Determinant’s of HealthFramework expands the representation of humans to be part of alarger ecosystem in which survival depends on a balanced interrelationship and sustainable use of resources.1.Further explorationinto the intersection of SDoH and EDoH is needed. For example,there is growing evidence of the socio-economic disparities betweenthose living in low income and marginalised communities and thepossibility of them suffering from higher temperatures compared tothose living in high income neighbourhoods. This could be a pathway for future research. Hancock and Spady1(p18) mention that “weneed to revise our population health frameworks to become truesocio-ecological models that give greater weight to the EDoH andto interactions between them and the SDoH”. The revised model ofthe Mandala of Health developed in this study adds to the limitedliterature assessing current models exploring the Anthropocene.This research can encourage the development of innovative modelsthat are better suited in designing sustainable solutions. However,conceptual models are to be treated as a tool that supports an understanding of a system that adapts to new understandings and different applications rather than a way to develop a theory and beinga fixed paradigm.63Study participants identified culture as a major influencingfactor on people and their environment. For example, facets ofwestern culture (eg the use of cars as our predominant mode oftransport, consumption of single-use products and non-recycling/throw-aware culture of society) can negatively influence the natural environment and ultimately health. The sentiment of participants was there is a lack of understanding in health promotionabout the importance of engaging with and learning from othercultures, specifically with Traditional Owners. Ife and Tesoriero58support this and identify the anthropocentric perspectives ofwestern ideologies are barriers towards health promotion’s abilityto enact change in this domain. Furthermore, participants believedthat incorporating IKS could assist with the lack of understandingamong health experts regarding EDoH. There is much evidenceregarding the value of Traditional Ecological Knowledge (TEK) andhow it can contribute to conserving biodiversity and also providesolutions in reconciling the contrasting western and Indigenousparadigms.64,65 TEK is defined as ‘a cumulative body of knowledgeand beliefs, handed down through generations by cultural transmission, about the relationship of living beings (including humans)with one another and with their environment’66(p3). Participantsidentified language as an inhibiting factor in engaging with othercultures. Perhaps this type of TEK, which is commonly shared bystorytelling, arts and song, can be useful in enabling health promotion to evolve.64 TEK is fluid and flexible, enabling itself to evolvewith new understandings, contrasting to western knowledgesystems that are accessible in written form and media in whichcontext is often eliminated.64,65Although there are still challenges associated with incorporatingthese contrasting knowledge systems, future research could consider how health promotion practice can integrate IKS and culturalvalues. Further research could measure the health and environmental outcomes of health promotion practice which uses Indigenousunderstandings to address planetary health. This would help identify how health promotion practice might conflict with ecologicalsustainability goals and add to the much-needed empirical researchjoining health, culture and the environment.4.1 | Strengths and limitationsIt is important to recognise that the findings only provide a limitedinsight into such a complex discussion because of the qualitative nature of the study, small sample size and that the data were gatheredfrom single interviews only. The study recruited more academicsthan practitioners, which was unintentional due to time restraints onresponse times, thus the results may not have been consistent withfindings that might have been obtained from practitioners workingin the field. As it was a low risk ethics approved, the sampling strategy was limited in its reach, for example, the study was unable to intentionally include people from Aboriginal and Torres Strait Islanderbackgrounds. Despite the inclusion of practitioners and academicswith experience in culturally diverse communities, future researchwould benefit from a more deliberative approach to involving culturally and linguistically diverse participants. In summary, and nevertheless, the data collected does provide some new insights to the topicas a whole and creates a pathway for further research into this area.12 | LANGMAID et AL.5 | CONCLUSIONThis study has highlighted that there is room for improvement inAustralian health promotion in terms of addressing EDoH and CDoHin theory and practice. It suggests the numerous challenges facedby health promoters in the context of the Anthropocene, but alsothe potential priorities and strategies to guide health promotion efforts in the future. The study has investigated the application andrelevance of conceptual models, such as the Mandala of Health inthe context of 21st century health issues and creates a pathway forfuture model development.The paper highlights the view that, for too long humanity hasnot been effective in integrating or synergising efforts that meet theneeds of humanity’s health or the environment. The impacts beingborne out of the Anthropocene era have shown those results. Aparadigm shift in understanding our relationships with the environment and intrinsic connections to humans’ health is required. Thedeterminants of health that are currently understood are found indisparate models. Thus, it is time to expand the dialogue and includemore voices and perspectives in a collaborative, respectful manner.Using an established model such as the Mandala of Health has helpedin leading the way to a more inclusive understanding of those determinants and a planetary health perspective. The current modelproposed takes the understanding of EDoH and CDoH further andprovides an opportunity for further dialogue and refinement to occurto benefit the promotion of health with due respect of the environment. If health promotion can better reflect the interrelationship between health and the natural environment, then health promotioncan become an indispensable tool in offering solutions for anthropogenic environmental damage and better health outcomes for futuregenerations to come. To strengthen this message even further futureresearch could focus on other factors such as economic elements andhave a larger sample size to validate these results.ACKNOWLEDG EMENTSThe authors thank Dr Trevor Hancock for providing his insights intothe making of the Mandala of Health framework during this study.The authors also thank the anonymous academics and practitionersfor their willingness to participate in the study and the feedback theyprovided on the revised framework proposed in this paper. 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