Population awareness about the impact of environmental factors on their health: tackling the complexity with appropriate statistical modeling. Examples from the Italian risk factor surveillance system.

Awareness of planetary health, i.e., the understanding of how environmental changes affect human health and wellbeing, is a crucial yet often underestimated prerequisite for the effectiveness of climate change mitigation and adaptation policies. Individuals’ awareness shapes risk perception, supports behavioural change, and public acceptance of environmental and health interventions. This is especially relevant for climate-sensitive health threats, whose emergence and geographic expansion are driven by rising temperatures, altered precipitation patterns, and environmental degradation. Despite their growing relevance, awareness of these indirect and often delayed health impacts of environmental change remains poorly understood.

This study contributes to this challenge by investigating how individual- and territory-level factors jointly shape subjective environmental perceptions, a key dimension of planetary health awareness. Environmental perception encompasses visible and immediate stressors, such as pollution, as well as broader concerns about ecosystem change and associated health risks, including the spread of infectious and vector-borne diseases affecting both human and animal health. These perceptions may influence preparedness, adaptive behaviors, and support for preventive interventions. 

We analyze data from the environmental module of PASSI (Progressi delle Aziende Sanitarie per la Salute in Italia), the Italian national health surveillance system, and integrate them with contextual information at the municipal level. Covariates include socio-economic indicators, PM2.5 exposure, and geographical features linked to climate-related risks, including those associated with vector ecology and disease transmission. This integrative framework reflects the inter- and trans-disciplinary nature of planetary health research, combining public health surveillance, environmental epidemiology, and spatial socio-economic analysis. Methodologically, we adopt a penalized semi-parallel cumulative ordinal regression model to address the ordered nature of environmental perception outcomes while allowing for flexible, non-parallel effects of high-dimensional selected covariates. Beyond inference, the model is used as an analytical tool to identify determinants most strongly associated with positive environmental perceptions and with neutrality, the latter interpreted as a potential indicator of limited or uncertain planetary health awareness.

The results reveal substantial heterogeneity across Italian territories, indicating that local environmental and socio-economic contexts play a central role in shaping awareness. Individual characteristics interact with contextual conditions in complex ways, confirming that planetary health awareness emerges from multi-level processes. Greater exposure to hazardous environmental factors, particularly elevated PM2.5 concentrations, is associated with poorer environmental perception, suggesting that respondents can recognize specific environmental stressors that may also serve as proxies for broader climate-related health risks, including vector-borne diseases.

This work demonstrates how combining health surveillance data with contextual environmental information and advanced statistical modeling can enhance the understanding of planetary health awareness. The findings provide policy-relevant insights to support place-sensitive, wellbeing-centered interventions aimed at strengthening public awareness and resilience to climate-driven health threats affecting humans, animals, and ecosystems.

Authors are funded by the European Commission grant 101136652. The five Horizon Europe projects, GO GREEN NEXT, MOSAIC, PLANET4HEALTH, SPRINGS, and TULIP, form the Planetary Health Cluster. The views and opinions expressed are only those of the authors and do not necessarily reflect those of the European Union or the European Commission. Neither the European Union nor the European Commission can be held responsible for them.