Factors affecting childhood exposures to urban particulates (FACE-UP)

Urban air pollution affects the health of hundreds of millions of people around the world. In SE Asia, 800,000 deaths were attributed to particulate air pollution (PAP) - the tiny dust particles that pollute the air - in 2012, alone. This is a particular issue for children because early exposure is directly attributable to life-long vulnerability to respiratory diseases. Finding appropriate, sustainable and innovative mechanisms for their protection is essential to ensuring resilient and productive societies in the future. This is the primary challenge to which the FACE-UP project responds.

Airborne particulates are hard to avoid. They not only pollute outdoor air, but also contaminate the indoor environment so children are exposed at home and school, as well as during outdoor travel, play, and exercise. Reducing exposure to PAP is one of four crucial actions identified by our partner UNICEF in their framework for improving children's health.

The best way to reduce exposure is to curb the production of pollutants (known as emissions reduction), but this is a slow and difficult task involving profound shifts in policy, legislation and infrastructure. Until air quality reaches safe levels, governments and NGOs must 'face-up' to the fact that communities are taking protection into their own hands, commonly through wearing facemasks, which may not be effective for children. Those who exercise their right to protect themselves and their children must be provided with the best evidence on how to do this in ways that are affordable, accessible and, crucially, complement their cultural environments. A key goal of FACE-UP is to elucidate how local factors affect the way that communities can protect their children from PAP, and to harness this information to ensure that appropriate advice and support can be freely accessed and, where appropriate, policies enacted to alleviate risk.

FACE-UP is a consortium of PAP exposure, social, behavioural and health scientists, statisticians and local and international agencies whose expertise lies in the interrelationship between the environment and children's health. We will work with urban children in two developing countries, Indonesia and Nepal, which both exhibit severe PAP but have differing contexts, being home to different cultures, climates, socioeconomics, built environments and policies. These factors not only impact the potential for ill health, but people's motivation, opportunity and capability to reduce children's exposure to PAP.

We will determine how, when and where children are exposed, as well as current protective measures (if any). Sensitive to, and influenced by, the feasibility of different practices, we will develop and assess the effectiveness of different types of protective actions, such as behaviour changes at home and school, and personal actions like wearing facemasks, and will estimate the potential health impact that can be achieved through adoption of these practices. Working with the communities to capture primary data on their cultural contexts, the project will also seek to understand the logistical factors that influence uptake (e.g. availability of education, political barriers and material supply chains) and how people might best learn about the practices. Ethical issues of agencies recommending practices that may not be very effective or affordable also will be evaluated. Robust data collection and analysis will feed directly into co-created and evaluated solutions, such as informational products, in partnership with local children, carers and agencies, which will be disseminated locally and globally, facilitated by our partner organizations.

The FACE-UP evidence will support ethical policy decisions, and individual actions to implement interventions, so that, combined with emissions reduction strategies, the world's children will grow up with the evidence to reduce their risk of developing diseases from air pollution exposures.

The 2019 State of Global Air report confirmed that LMICs suffer PM2.5 concentrations which are 4-5 times those of HICs, and that this correlates with attributable diseases, deaths and reduction in life expectancy. Today's LMIC children are thus predicted, throughout their life-course, to have substantial risk of illness and reduced earning potential. FACE-UP will build evidence for culturally-relevant protective actions to decrease children's exposure to PM2.5 in cities in Indonesia and Nepal. Specific objectives and methods are: 1) To compare country contexts by: a) assessing children's exposures via ambient and personal PM2.5 monitoring, b) identifying potentially feasible protective actions with communities and agencies, c) assessing community and policy-level drivers that will influence behaviour change using social research (focus groups, interviews and questionnaire surveys) with children, parents/guardians, teachers, and policy makers, and d) evaluating children's and adults' learning behaviours; 2) To develop and test context-sensitive practices to reduce children's exposures at home, school and when outdoors, including: a) personal actions such as facemask use, building adaptations and affordable air purifiers, and b) a health impact assessment of their potential to reduce NCDs; 3) To promote sustainable behaviour change via a holistic assessment of: a) ethical issues, policy requirements, and logistics of access to affordable, effective intervention materials, and b) co-development (with children, carers and practitioners) and evaluation of informational products to maximise their usefulness and uptake at a local and global level, via agency websites/social media, schools and dissemination campaigns. The FACE-UP evidence will support ethical policy decisions, and individual actions, so that, combined with emissions reduction strategies, the world's children can grow up with the ability to reduce their risk of developing diseases from PM2.5 exposures.

We have identified four key stakeholder groups with which the FACE-UP team plans to engage over the duration of the project, and beyond:
1) The communities with which we work in Bandung and Kathmandu, across a number of neighbourhoods, likely accessed through schools/Parents Associations to which we will be introduced via our local practitioner partners.
2) The wider public, in Indonesia, Nepal and in other countries, who will use the informational products to inform their decisions on how to protect their children.
3) The practitioner project partners (see CfS and PtI), consisting of municipal, national and international non-governmental and governmental agencies based in Nepal, Indonesia and at a global level, and the International Society for Respiratory Protection (ISRP), who have proposed a programme of work as part of the project.
4) Cognate agencies tasked with the protection of children from air pollution (e.g., Ministries of health, environment, social work and civil protection) in countries affected by air pollution. Humanitarian agencies and community-based health and social workers responding to air pollution crises (e.g. wildfires or volcanic eruptions) will also benefit.

The research will benefit the public, policy makers and practitioners in the following ways:
There is a dearth of information on how carers can effectively reduce children's inhalation of airborne particles, potentially encouraging behaviours which actually increase exposure (e.g. assuming children are protected when wearing an ineffective, poorly-fitting facemask). This is exacerbated by numerous media articles providing non-evidence based information. The research will have immediate impact, providing critical evidence that empowers individuals to make informed decisions on protective measures for their children. This will be done via local and global dissemination, enabled by the media platforms of our major project partners WHO, UNICEF and Red Cross, of informational products co-designed by the practitioner partners, communities and research team. We anticipate that, through press releases, and journalist engagement, the findings will garner substantial media attention, hopefully leading to evidence-based advice in future media articles.

At the policy level, the policy brief and ethical frameworks will enable agencies and practitioners to make informed decisions when planning how and whether to implement culturally-specific behavioural intervention activities (e.g. education, incentivisation, training) to increase carers' and their children's capability, opportunity and motivation to take up exposure reduction practices. The findings will likely show that some interventions are not effective, safe, affordable or available in specific contexts, so the research will also inform decision making in that respect. Such decision making would start at the close of the project and continue into the future as further evidence becomes available.

The uptake of evidence-based practices, in partnership with increased awareness of the likely exposure reduction potential of those actions, will reduce ineffective behaviours and increase the quality of air inhaled by children. The research will quantify how widespread uptake of the interventions, at various levels of use and effectiveness, will benefit children's health, in the investigated cities, those countries and in the wider regions. By reducing exposure to particles, the risk of developing a range of childhood and adult diseases will be reduced. In the long term (generational), this will lead to greater potential for the achievement of sustainable development goals through the capability of future adults to work, lead healthy lifestyles and to prosper.

We have a longer term ambition to explore the commercial potential of developing protective products (especially facemasks designed for children's faces, with ISRP) and preliminary scoping will take place within the FACE-UP project.