Environmental Health

Tamara Rose

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Objectives

Upon completion of this chapter, the reader will be able to do the following:

1. Describe areas of environmental health, environmental health problems, and related human health risks.

2. Apply the basic concepts of critical theory to environmental health nursing problems.

3. Describe the importance of air, water, and food quality as a determinant of health.

Outline

- A Critical Theory Approach to Environmental Health, 265 Areas of Environmental Health, 267 The Built Environment, 268 Work-Related Exposures, 269 Outdoor Air Quality, 271 Food Safety, 274 Waste Management, 275 Effects of Environmental Hazards, 277

Key Terms

4. Identify social, cultural, economic, and political factors that contribute to pollution and affect environmental problems.

5. Develop an understanding of the risk assessment and risk management role of nurses.

6. Explain laws and regulations relevant to environmental health and how government agencies use them to address environmental issues.

Efforts to Control Environmental Health Problems, 278 Emerging Issues in Environmental Health, 278 Nursing Actions, 279 Approaching Environmental Health at the Population Level, 279 Critical Environmental Health Nursing Practice, 280

Taking a Stand: Advocating for Change, 280 Asking Critical Questions, 280 Facilitating Community Involvement, 281 Forming Coalitions, 281 Using Collective Strategies, 281 Bibliography, 284

Table summary: The table provides a comprehensive list of keywords and thematic categories related to environmental health, public health risks, and social determinants of health.

The World Health Organization (who) (2021) refers to environmental health outcomes as “clean air, stable climate, adequate water, sanitation and hygiene, safe use of chemicals, protection from radiation, healthy and safe workplaces, sound agricultural practices, health-supportive cities and built environments as well as the preservation of nature.” “As a fundamental component of a comprehensive public health system, environmental health works to advance policies and programs to reduce chemical and other environmental exposures in air, water, soil, and food to protect residents and provide communities with healthier environments". figure 14.1, from the U.S. Department of Health and Human Services Healthy People 2030 program, demonstrates these factors.

Figure 14.1 summary: This figure is a conceptual diagram. It illustrates various elements of environmental health as defined by the Healthy People 2020 initiative, centering on a diverse group of people. The surrounding elements include water quality, toxic waste management, global environmental health, infrastructure and surveillance, healthy homes and communities, and outdoor air quality. The diagram suggests that human health is intrinsically linked to and influenced by a broad spectrum of environmental factors ranging from local living conditions and infrastructure to global ecological stability.

Environmental health experts believe that the purpose of environmental health is to assure the conditions of human health and provide healthy environments for people to live, work, and play. This can be accomplished through risk assessment, prevention, and intervention.

Efforts are made to reduce and eliminate contaminant and contagion threats to human health from air, water, food, and the built environment. Maintaining a healthy environment is vitally important to promoting the health of populations—particular groups or types of people. A healthy environment improves quality of life and increases years of healthy living. Accumulated evidence shows that the environmental changes of the past few decades have profoundly influenced the status of public health. Globally, environmental risk factors, including air, water, and soil pollution, exposure to chemicals, radiation, and climate changes, contribute to nearly 25% of all deaths and increase disease burden. The safety, beauty, and life-sustaining capacity of the physical environment are unquestionably of global consequence. Since the beginning of the 21st century, it has become apparent that the world must address urgent environmental difficulties, including extinction of some species, diminishing rainforests, proliferation of toxic waste dumps, progressive destruction of the ozone layer, shortage of landfill sites, consequences of climate change, threats of terrorism, development of deadly chemical and ballistic weapons, adulteration of food by pesticides and herbicides, oceanic contamination through toxic dumping and petroleum spills, overcrowding of urban areas, and traffic congestion.

This chapter uses critical theory to explore the health of communities in relation to the environment. Critical theory is particularly useful in examining environmental health because it offers a framework for discussion and a basis for describing community health nursing practice. Applying critical theory is a way of thinking upstream (see Chapter 3). Critical theory is an approach that raises questions about oppressive situations, involves community members in the definition and solution of problems, and facilitates interventions that reduce health-damaging effects of environments. By applying the nursing process in a critical fashion, nurses can be dynamically involved in the design of interventions that alter the precursors of poor health.

Recognition of the gravity and pervasiveness of environmental hazards can be overwhelming. Looking beyond the individual to recognize the environmental determinants of health can be complicated and alarming. Intervening to improve the quality of air, water, housing, food, and waste disposal and reducing the risks of harmful exposures to environmental toxins require individual, social, economic, and political changes. Nurses are powerful change agents who use their assessment, management, and communication skills to promote environmental health locally and nationally. Nurses are becoming increasingly active in efforts to address environmental health issues and to increase awareness of the effects of the environment on well-being.

A Critical Theory Approach to Environmental Health

Critical theory suggests that nurses must be aware of environmental threats or factors that might detrimentally affect the safety and well-being of particular populations or deprive them of access to resources necessary in the pursuit of health. This awareness may include recognizing, supporting, and maintaining positive environmental influences. For instance, a nurse must consider the effects of having access to a safe place to walk on one's ability to maintain healthy levels of physical activity. Research studies indicate that access to recreation facilities is an important correlate of physical activity. Nurses can help individuals adopt healthy behaviors by considering not only individual-level issues but also those issues in the environment that facilitate or create barriers to healthy living.

Nurses need to ask critical questions about their clients' environments to help discern the contributions of specific hazards to their health. Occupational exposure to environmental hazardous can cause harm to workers as well as their families. For example, farm workers and pesticide applicators who accumulate agricultural chemicals on their skin and clothing take these substances home with them, increasing their children's exposure to toxicants. Nurses must provide answers to farm workers who ask questions such as"What do I do if I'm exposed to a pesticide?"

How long should I wait until after a pesticide application to go back into the field? How do I find out how toxic a certain pesticide is? Where can I get information on a specific pesticide?" Nurses can take an environmental health history. An environmental health history can benefit the client in the following ways:

• Increase awareness of environmental health concerns

• Improve timelines and accuracy of diagnosis

• Prevent disease and aggravation of conditions

• Identify potential environmental hazards

Environmental health histories should be obtained for both adults and children, although the relationship between the environment and children's health is frequently overlooked. figure 14.2 demonstrates common assessment items of an environmental history. When looking at the community from a critical perspective, nurses have the opportunity to promote population health.

In identifying environmental sources of health problems, nurses must be involved with the affected communities. Rather than impose their views of the problem, nurses should share their ideas and dialogue with community members. For example, nurses should listen to what the community believes is problematic, help raise consciousness about environmental dangers, and help bring about change. If nurses become involved in conducting community assessments and analyses, they can learn how the community members perceive themselves, their health, and their environmental influences.

From a critical standpoint, helping communities become more aware of the environmental effects on health and helping them make needed changes in their environment are legitimate nursing actions. Collective actions have been instrumental in accomplishing positive environmental changes since the 1980s. Some of the mechanisms have included strategic organization, litigation, public hearing testimony, letter-writing campaigns, legislative lobbying, mass demonstrations, and fundraising. Fundraising for environmental causes such as the 2012 storms that devastated the Northeast United States and the 2010 earthquake in Haiti facilitated rapid availability of resources, minimized loss of life, and helped restore basic necessities such as clean water and shelter. Public response to “acute” environmental disasters needs to be extended to an ongoing, consistent pressure to ensure day-to-day environmental integrity; hence “chronic” environmental problems need to be addressed more effectively.

1. Do you live next to or near an industrial plant, commercial business, dump site, or nonresidential property?

2. Have you been exposed to hazardous materials at work now or in the past?

3. Which of the following do you have in your home?

__ air conditioner _ _ air purifier _ _ central heating (_ _ gas _ _ oil)

__ gas stove

_ humidifier

_ fireplace

_ _ wood stove

4. Have you recently acquired new furniture or carpet, refinished furniture, or remodeled your home?

5. Have you weatherized your home recently?

6. Are pesticides or herbicides (bug or weed killers; flea and tick sprays; collars, powders, shampoos) used in your home, garden, or on your pets?

7. Do you (or any household member) have a hobby or craft?

8. Have you ever changed your residence because of a health problem?

9. Does your drinking water come from a private well?

10. Approximately what year was your home built?

11. Has your routine changed recently?

12. Does anyone in your household smoke?

13. Has your home been tested for radon?

A critical perspective can help nurses plan and implement population-level interventions by emphasizing collective strategies for change. Acting collectively can empower nurses to affect environmental health. Assessing environmental health problems, planning and implementing interventions, and evaluating the effectiveness of community-based actions need to be based on a wide lens. Community health nurses should be familiar with physical surroundings and their mutual interaction with cultural realities, social relations, economic circumstances, and political conditions of communities, applying a critical perspective to community health.

Areas of Environmental Health

Environmental health hazards are ubiquitous in communities across the United States and place people at risk for disease or injury. This chapter divides the vast field of environmental health into the following subcategories: the built environment, work-related exposures, outdoor air quality, healthy homes, water quality, food safety, and waste management (Table 14.1). A brief discussion introduces nurses to these seven areas of environmental health, describes how they affect health, and demonstrates basic strategies nurses can use to address them. Table 14.2 provides examples of health problems within each area of environmental health.

Table 14.2 summary: This table categorizes a wide array of environmental health problems across several domains, illustrating how various areas such as the built environment, outdoor air and water quality, food safety, waste management, and home and work settings contribute to diverse public health risks.

It should be noted that a critical perspective does not separate the idea of a safe social environment from a safe physical environment. For example, interpersonal violence is a significant and growing risk, with consequences ranging from bodily injury to psychiatric aftereffects that may last for decades in some individuals. Intergenerational patterns of abuse, hate crimes toward marginalized groups, sexual predators, and hazards of combat might be considered from an environmental health perspective. Issues of violence are discussed in more depth in Chapter 27.

Table 14.1 summary: This table provides a comprehensive overview of the various domains within environmental health, defining key areas such as the built environment, occupational exposures, air and water quality, housing safety, food security, and waste management.

Finally, we must be prepared for the public health effects of terrorism. Terrorism is a word that evokes many images and a range of reactions from rage to grief and loss. Acts of terrorism have drawn the public and political focus to establishing environmental security. Bioterrorism and homeland security are new areas where nurses will have an impact. A critical perspective is needed now more than ever, because security issues are linked to religious imperatives, moral stances, values, profit motives, healthcare systems and information, and cultural differences. These issues are also clearly within the scope of community health nursing and are discussed in more detail in Chapter 28.

The Built Environment

The built environment consists of the connections among people, communities, and their surrounding environments that affect health behaviors and habits, interpersonal relationships, cultural values, and customs. There is growing evidence that the built environment directly and indirectly affects health outcomes and disease rates (Table 14.3). One review of the literature found that neighborhoods that are more walkable are associated with increased physical activity, increased social capital, lower overweight, lower reports of depression, and less reported alcohol abuse. Social capital refers to networks and the associated norms and expected collective benefits derived from cooperation between individuals and groups. Structural characteristics of the built environment, such as street condition, neighborhood deterioration, and the proportion of parks and playgrounds, affect levels of physical activity and obesity found that women are more likely to increase physical activity if they live in a walkable community compared with men, indicating safety to be an attributing factor. Simply put, having a safe, intact place to walk may encourage exercise among adults.

Table 14.3 summary: This conceptual model illustrates the causal flow from the built environment to health outcomes. It shows how structural elements like land use and infrastructure create mediating exposures such as environmental toxins and noise, which then trigger behavioral, psychological, and physiological responses that ultimately determine individual and population-level health status.

Many people live within areas that require almost daily contact with potential health risks and threats. These include intoxicated or impaired drivers, secondhand smoke, urban crowding, noise exposure, unabated traffic, and the stress of increased mechanization. The type of area one lives in can greatly affect one's health. For example, a research study found that adolescents living in rural working-class or mixed-race urban neighborhoods were more likely to be overweight than peers in newer suburbs, regardless of their socioeconomic status (S.E.S), age, or race/ethnicity. In another study investigating the role of neighborhood characteristics and childhood obesity, neighborhood S.E.S was found to be a greater mediator of childhood obesity than racial or ethnic disparities. Access to equipment and facilities, neighborhood pattern (e.g., rural, exurban, suburban), walkability, and urban sprawl are also associated with obesity outcomes in adolescents.

Urban sprawl has been defined as the conversion of land to nonagricultural or nonnatural uses at a faster rate than the population growth. The sprawling development often occurs more rapidly than the expansion of the infrastructure (e.g., schools, sewer systems, water lines) needed for support. The urban sprawl is characterized by four dimensions: “low residential density; rigidly separated homes, shops, and workplaces; roads with large blocks and poor access; and lack of well-defined activity centers”. Consequences of sprawl include air and water pollution, floods, infrastructure expenses, and a decrease in natural areas and forests.

One unfortunately common problem associated with living patterns relates to residing near hazardous facilities (e.g., waste incinerators, sewage treatment plants, landfills, refineries, and some correctional facilities). Molitor et al. (2011) found that higher levels of pollutants are generally associated with higher poverty. Discriminatory land use ensures that many impoverished and marginalized groups, especially minorities, live in close proximity to industrial contamination. People who live near such environmental hazards are in danger of becoming victims of illness and injury related to violence, poisonings and exposures, fires, and malignant and nonmalignant diseases. Clinical Example 14.1 provides an example. Though historically outdoor pollution and hazards have been considered the major contributors affecting environmental quality, one must also consider the influence of indoor residential environmental hazards, such as radon, asbestos, lead, insect and pet allergens, chemicals, and other consumer products, as well as secondhand smoke and fungi.

Many communities lack sufficient resources to respond when urban development and technological advances jeopardize the health and well-being of families in affected areas. The environmental movement of the 1960s and 1970s succeeded in building political power capable of passing monumental environmental reforms; however, charges that poor and minority communities are dumping grounds for environmental hazards have been substantiated by governmental agencies.

Difficulties in alerting state and federal officials about environmental health dangers, as well as in obtaining compensation for environmental toxin-causing disease and death, often result in resident revictimization. Tightly knit social structures and a lack of low-cost housing may hinder the mobility of residents and perpetuate the exposure to health hazards. Residents may be unwilling to disrupt family ties and cultural roots to start over elsewhere, or they may be unable to afford a move. These residents may live with uncertainty and conflict. Long-term, community-wide effects of division, animosity, distrust, cynicism, and despair can abound in these situations, negatively affecting social capital.

In the 1990s, the central issues of equity and justice emerged in environmental health policy. In 1994, President Clinton signed Executive Order (E.O) 12898, which required all federal agencies to develop comprehensive strategies for achieving environmental justice. This directive has served to increase public participation and access to information as well as provision of education about multiple risks and cumulative exposures (Box 14.1). A recent investigation of the impact of E.O 12898 determined the order failed to address an important contributor to environmental justice: poor economic growth in low-income minority communities. In 2008, President Obama signed a memorandum of understanding in regard to E.O 12898 to identify and address environmental justice at the program, policy, and initiative level. Nurses are part of the interdisciplinary team made up of urban planners, public health practitioners, and policy makers needed to understand and address issues of the built environment that are critical to establishing health equity.

Table 14.1 summary: The table lists landmark federal environmental legislation passed over several decades, showing a high concentration of major regulatory acts enacted during the early seventies, with subsequent laws appearing less frequently over time.

Clinical Example 14.1

In an urban city in the south, the health department is becoming increasingly concerned about the overweight and obesity rates of young school-age children. At health fairs held around the city, nurses are seeing more children with acanthosis nigricans, elevated blood pressure, high body mass index (B.M.I), and hypercholesterolemia. Though the public health nurse diligently counsels patients on the benefits of exercise, his patients do not increase their physical activity.

When the nurse drives around the neighborhood where many of his patients reside, he realizes there are no recreational parks nearby, the sidewalks are in disrepair, the smokestacks cloud the air, and there appears to be gang-related activity. The nurse considers the impact of the built environment on the ability of his patients to be physically active. In partnership with the school board and neighborhood watch group, the nurse and community members successfully petition for a park to be built within walking distance of the school.

Additionally, the partnership is able to establish a "walking school bus," a program where students walk in a group to or from school, as a way for children to increase their physical activity.

Work-Related Exposures

Work-related exposures can happen as a result of poor working conditions and can lead to potential injury or illness. Environmental health problems posed by work-related exposures include such issues as occupational toxic poisoning, machine-operation hazards (e.g., falls, crushing injuries, burns), electrical hazards, repetitive motion injuries, carcinogenic particulate inhalation (e.g., of asbestos, coal dust), and heavy metal poisoning. Prevention of work-related health problems requires integrated action to improve job safety and the working environment. Occupational and environmental health nurses often collaborate on initiatives to reduce and eliminate work-related exposures, illnesses, and injuries. Nurses can be sure that workers are aware of and know where to access the safety data sheets relevant to their workplace. The U.S. Department of Labor's Occupational Safety and Health Administration (O.S.H.A) requires chemical manufacturers, distributors, and importers to provide safety data sheets that communicate the hazards of chemical products.

According to the Bureau of Labor, approximately 2.9 million nonfatal workplace injuries and illnesses were reported by private industry employers in 2015. This rate continues a pattern of decline annually for the past 13 years, apart from 2012, where there was either equal or more days away from work because of injury compared with the previous year. The E.P.A estimates that 10,000 to 20,000 physician-diagnosed pesticide

Examples of Environmental Health Issues Affecting Communities

Image summary: This is a photograph. The image depicts several large industrial pipes discharging a yellowish liquid into a body of water, creating foam and turbulence upon entry. The surrounding environment consists of snowy banks and dormant vegetation. The scene indicates a significant release of pollutants or waste materials into a natural waterway, suggesting environmental contamination and potential ecological damage.

Image summary: This is a photograph. The image depicts a line of vehicles stopped in heavy traffic on a roadway, with thick plumes of exhaust smoke emanating from the rear of several cars. The scene shows a congested urban environment with multiple lanes of cars stretching into the distance. The prevalence of dense exhaust emissions suggests poor air quality and high levels of pollution resulting from vehicle congestion.

Image summary: This is a photograph. The image shows an industrial facility located along a riverbank, featuring multiple smokestacks emitting large plumes of white smoke that drift across the site. In the background, a bridge spans the river, and a distant city skyline is visible under a hazy sky. The scene indicates significant industrial activity and the resulting emission of pollutants or steam into the atmosphere, suggesting a high level of environmental impact in the surrounding river valley region.

Image summary: This is a photograph. The image shows a concrete sidewalk stretching into the distance, flanked by grassy areas. The pavement is heavily weathered, featuring numerous cracks and a significant hole in the foreground. The condition of the walkway suggests a lack of maintenance and significant deterioration over time.

Image summary: This is a photograph. It depicts two medical professionals wearing sterile gear, including caps, masks, and gloves, while performing a procedure on a biological specimen, specifically a large bone, which is placed in a tray. The image suggests a medical training or forensic examination setting where practitioners are analyzing or dissecting anatomical structures to gain clinical knowledge or evidence.

poisonings occur each year among the approximately two million U.S agricultural workers. In 1 year (2010), 476 farm workers died from work-related injuries, with tractor overturns being the leading cause of death.

These statistics do not reflect unreported health problems. For example, a clerical worker leaves the office every day with back strain and a headache because of ventilation problems in the building. After 5 years on a repetitive hand-movement job task, an employee is diagnosed with carpal tunnel syndrome.

An operating room nurse has a miscarriage and recalls that many of her coworkers have also been unable to carry their babies to term. A dry cleaner often leaves work feeling light-headed and dizzy from inhaling solvents at the shop, and 1 day she has a car accident on her way home. Collective problems related to employment or occupation are often perceived as individualized injuries, and no one “connects the dots.” Research is ongoing to determine the outcomes of work-related environmental exposures. For example, the GuLF Study (Gulf Long-Term Follow-Up Study) is a health study, sponsored by the National Institutes of Health (N.I.H), for individuals who helped with oil spill clean-up after the 2010 Deepwater Horizon disaster in the Gulf of Mexico. Clinical Example 14.2 illustrates another case of work-related exposure.

Clinical Example 14.2

Sanitation workers in an urban area experienced a rising incidence of puncture injuries while transporting hazardous wastes from the public medical center; these puncture injuries caused several cases of hepatitis. When the story became public, members of the city health commission contacted community health nurses and instructed them to politically support the interests of the city and the medical center "at all costs." Subsequently, the sanitation workers' union contacted the community health nursing office and requested information about procedures for safely packaging medical wastes. They also requested that a nurse speak to their membership about immediate measures for preventing further injuries on the job.

The nurses met to resolve the conflict. Most agreed that the sanitation workers had pressing needs for education and support. Despite the city's demand for loyalty, they decided to "choose sides" with the workers and respond to their requests.

They collectively drafted a letter to the city health commission and arranged a meeting with the commissioners to discuss their plan to assist the sanitation workers. The health commission held a press conference, which depicted the nurses' actions as mediational efforts that benefited the union and the city. Eventually, the nurses and the commission developed a new medical waste disposal plan, and injured workers received reasonable compensation through an out-of-court settlement.

Outdoor Air Quality

Outdoor air quality refers to the purity of the air and the presence of air pollution. The E.P.A (2012b) has classified six common air pollutants (Table 14.4). who estimates that air pollution contributes to approximately seven million premature deaths annually worldwide. Particulate matter, one common pollutant, causes worsening respiratory symptoms, more frequent asthma-related medication use, decreased lung function, recurrent health care utilization, and increased mortality.

Air pollution originates from industry (dry cleaning, factories, oil refineries, coal-burning power plants), modes of transportation (cars, buses, trucks, and planes), and naturally occurring events (volcanic eruptions and windstorms). Tornadoes, electrical storms, smog, gaseous pollutants (e.g., carbon monoxide), excessive hydrocarbon levels, aerial herbicide spraying, and acid rain all contribute to air pollution. Under provisions of the Clean Air Act, the E.P.A sets the national ambient air quality standards for pollutants considered harmful to humans or the environment.

Ozone is the most common pollutant in the United States and is the primary component of smog. Ozone is formed when nitrogen oxides (created by the burning of fossil fuels in power plants, automobiles, and factories) react with oxygen and sunlight. Ozone, along with other hazardous atmospheric pollutants, causes and/or contributes to asthma, allergic reactions, bronchitis, lung cancer, chronic respiratory disease, and death and harms animal and plant species. Furthermore, sulfur dioxide, a by-product of burning coal and other fossil fuels, contributes to acid rain, which affects terrestrial ecosystems by increasing soil acidity, reducing nutrient availability, mobilizing toxic metals, leaching soil chemicals, and altering species composition. Two significant issues related to outdoor air quality are of global concern. First, the amount of protection in the atmospheric layers is diminishing. Chemicals such as chlorofluorocarbons, halons, and carbon tetrachloride, which have been in widespread use for refrigeration, air conditioning, and aerosol propellants, remain in the atmosphere. These molecules cause depletion of the atmosphere's protective ozone layer.

The resulting "holes" in the ozone layer allow excess ultraviolet radiation to penetrate, which has harmful effects on many organisms. Long-term problems include increases in rates of skin cancer and cataracts, suppression of immune response, and environmental damage.

Second, there is a disruption in the key processes that break down atmospheric carbon dioxide. The ongoing deforestation of the earth's surface, especially the diminishing of tropical rainforests, not only releases the carbon stored in the biomass but also eliminates sources of photosynthesis (i.e., the process by which plants absorb carbon dioxide and release oxygen). The loss of carbon dioxide—consuming resources increases carbon dioxide and traps part of the heat reemitted by the earth.

As a result, the earth's surface temperature is rising (i.e., the "greenhouse effect"), with potentially catastrophic ecological consequences. Global climate change, including evidence that glaciers are shrinking, ice on rivers and lakes is breaking up earlier than usual, and a shift in plant and animal ranges, has already been observed.

Table 14.4 summary: This table outlines various major air pollutants, identifying their primary sources and their adverse effects on human health and the environment. Most of these pollutants originate from industrial processes and vehicle emissions, with common health impacts including respiratory impairment and cardiovascular stress, particularly for vulnerable populations such as children and those with pre-existing conditions. Some pollutants also cause significant environmental damage, including vegetation injury and the acidification of water bodies.

In 1968, the National Air Pollution Control Administration developed the air quality index (A.Q.I) to increase public awareness of air pollution (Fig. 14.3). The A.Q.I is a number used by government agencies to communicate current and forecasted air pollution conditions to the public. As the A.Q.I rises, a larger percentage of the population, particularly vulnerable populations, may experience adverse health effects. The A.Q.I fluctuates on the basis of the dilution of air pollutants.

Air stagnation can lead to high concentrations of pollutants and haze. Although most air contaminants do not have an associated A.Q.I, many countries monitor ground-level ozone, particulates, sulfur dioxide, carbon monoxide, and nitrogen dioxide to calculate the A.Q.I. Nurses need to be aware of the A.Q.I and the corresponding recommendations for the public to limit exposure to outdoor air during peak times of high A.Q.I. Additionally, nurses must consider the A.Q.I when making recommendations for physical activity, particularly for asthmatic patients. One study suggests that population-level health benefits from increased physical activity in high-walkability neighborhoods may be offset by the adverse effects of exposure to air pollution. A recent study on the effects of particulate matter for individuals who walk or cycle to work found that the health benefits of active travel far outweighed the health risks from air pollution.

Clinical Example 14.3

During a recent summer, a sudden increase occurred in the number of clinic visits from residents of a particular urban neighborhood. The patients were elderly men and women who felt ill after going for a walk and asthmatic children with worsening respiratory symptoms. A nurse at the federally qualified health clinic in the neighborhood suspected that air pollution might be contributing to the increase in health concerns.

The nurse went online to the site www.airnow.gov and searched for the A.Q.I for the region. She discovered that the region was experiencing a very unhealthy level of outdoor air pollution. She immediately alerted the healthcare staff that people with heart or lung disease, older adults, and children should avoid all physical activity outdoors and that everyone should avoid prolonged or heavy exertion outdoors.

The nurse contacted the local summer camps and nursing homes in the area to alert them of the recommendation. The clinic quickly decided to move their regularly scheduled outdoor picnic to an indoor venue. One week later, the nurse noticed a drop in the number of patients complaining of respiratory distress.

Healthy Homes

A Healthy Home refers to the availability, safety, structural strength, cleanliness, location, and indoor air quality of shelter. According to the E.P.A (2017), many of the health concerns related to indoor living are a result of exposure to radon, carbon monoxide, molds and dust, secondhand smoke, cooking vapors, lead paint, and rodents. The C.D.C and surgeon general have developed a Healthy Home checklist that nurses can use with patients to guide a thorough assessment and develop a care plan to help patients improve the quality of their homes and their indoor air quality.

Radon causes an estimated 21,000 lung cancer deaths in the United States every year. It is the second leading cause of lung cancer, after active smoking, and the leading cause among nonsmokers. Nine federal agencies in 2011 initiated a plan to reduce radon exposures and illnesses. Four years after implementation of the Federal Radon Action Plan (frap), the E.P.A joined forces with other lead agencies and sectors to develop the National Radon Action Plan (nrap) with goals to mitigate five million high radon homes. and save 3200 lives annually from death related to lung cancer. Carbon monoxide is an odorless, colorless, toxic gas. It can cause mild flulike effects such as headaches, dizziness, disorientation, nausea, and fatigue at lower levels of exposure and death at higher levels. Molds, dust, and secondhand smoke exposure can often exacerbate asthma symptoms.

Other health problems related to housing include fire hazards; lack of accommodations for people with disabilities; illnesses caused by overcrowding; psychological effects of architectural design (e.g., low-cost, high-rise housing projects); injuries sustained from collapsed building structures; and exposure deaths from inadequate indoor heating or cooling. Poor housing conditions can contribute to the spread of infectious disease as well as cardiovascular and respiratory disorders, cancers, allergies, and mental illnesses. The term sick building syndrome describes a phenomenon in which public structures and homes cause occupants to experience a variety of symptoms, such as headache, fatigue, and exacerbation of allergies. It typically results from poor ventilation and building operations, hazardous building materials, furniture and carpeting substances, and cleaning agents (E.P.A, 1991). Additionally, volatile organic compounds (V.O.C's) have been found in soil and soil vapor as a result of industrial spills that contaminate indoor air. One such spill in Endicott, New York, has been linked to congenital cardiac defects, low birth weight, and fetal growth restriction.

Other problems may arise related to building structures, composition, and settings. For example, commercial buildings with offices near underground parking garages may cause workers to have carbon monoxide intoxication. Formaldehyde, asbestos, and V.O.C's—which are common components of thermal insulation, cement, flooring, furnishings, and household consumer products—have carcinogenic properties. Additionally,"toxic mold" arising from chronically damp wood and improperly sealed areas in homes and offices has been recognized as contributing to respiratory irritation, allergies, and infections in susceptible individuals.

Clinical Example 14.4

In a large, northeastern U.S city, an economic recession led to large company layoffs, leaving many unemployed or underemployed. Because of the loss of income, many families faced tough decisions during the upcoming winter months. Temperatures often went below zero, requiring constant heating. Unfortunately, many people did not have the money to continue to pay their heating bill, fix leaky windows and doors, or buy warm clothes.

Some families began to use space heaters and burned scraps of wood that were discarded. Often, this wood came from old abandoned buildings and homes. Other families took to sleeping in their cars.

Clinical Example 14.4—cont'd

Soon, hospitals began to see an uptick in patients presenting with respiratory illnesses, carbon monoxide exposure, and burns. The community health nurses in the area met with struggling families to assess their needs and determine a plan to meet their immediate needs. The nurses met with local politicians and church groups to find ways to supply healthy wood for heating, help financially with home utility bills, provide warm clothes for families, and find shelters for homeless families. Within a few months, the local hospitals began to see a decline in home-related injuries and illnesses.

Water Quality

Water quality refers to the water supply's availability, volume, mineral content levels, toxic chemical pollution, and pathogenic microorganism levels. Water quality consists of the balance between water contaminants and the existing capabilities to purify water for human use and plant and wildlife sustenance. Water quality problems include experiencing droughts, dousing reservoirs with chemicals to reduce algae, contaminating aquifers with pesticides and fertilizers, leaching lead from water pipes, and oil spilling from transport tankers or leaking offshore wells. Other sources of water pollution are microbial contamination from poorly managed or maintained septic or sewage systems and animal feedlot wastes. Water pollution can be from point sources (a well-defined source, for example, factory wastewater discharge) or nonpoint sources (urban runoff, domestic lawn care, and air-to-water transfer).

Advances in water treatment technologies in industrialized countries have controlled many water-related diseases, such as cholera, typhoid, dysentery, and hepatitis A. Nevertheless, disease outbreaks resulting from contamination by untreated groundwater and inadequate chlorination are increasing in both urban and rural areas. In addition, more than 45 million Americans (15%) obtain their drinking water from private water supplies (e.g., wells) that have no treatment or monitoring guidelines. Other potential water contaminants include accelerated soil erosion caused by construction, agriculture, and deforestation, which can contribute to high sediment levels in drinking water supplies.

Heavy metal and toxic chemical pollution may also occur during the water treatment process or in the drinking water distribution system. The E.P.A monitors drinking water for more than 90 organic and inorganic pollutants that have potential health effects in humans, including those who are most vulnerable, such as children and people with weakened immune systems. Pesticides, herbicides, and carcinogenic industrial waste infiltrate an increasing amount of groundwater, the underground source of half the U.S population's drinking water. Additionally, commonly used medications and personal care products that contain endocrine disruptors have been found in water supplies. This development is particularly tragic because groundwater is uniquely susceptible to long-term contamination. Unlike river or lake water, once groundwater becomes contaminated, it is impossible to cleanse.

Clinical Example 14.5

In a Midwestern farm community, there is growing concern about seepage of agricultural pesticides and herbicides into groundwater. Families obtain water from private wells rather than a central municipal source. The families had heard about potential long-term carcinogenic effects of the chemicals, such as pesticides and herbicides, commonly used on the farms in the community. Although family farmers decreased their use of these chemicals, the large-scale agribusiness companies continued to use large amounts of these chemicals.

A community health nurse from the county health department lobbied local officials to begin a comprehensive program to monitor groundwater pollutants and enforce standards for herbicide and pesticide use. However, the powerful agribusiness companies pressured these officials to stand back. Together, some county farmers and nurses organized grassroots information and support groups for the rural families.

The families and nurses, in coalition with environmental activist groups in the state, established several projects. These projects included collecting and testing samples from each family well, forming a local organization called "Water Watch" to coordinate actions and communications, and implementing a research project with a local university to track water contamination and health problems of local residents. The organization also disseminated an emergency plan to families whose wells were found to have toxic levels of pesticides, herbicides, or other pollutants.

Food Safety

Food safety refers to availability, accessibility, and relative cost of healthy food free of contamination by harmful herbicides, pesticides, and bacteria. Food safety concerns include malnutrition, bacterial food poisoning (Clinical Example 14.6), carcinogenic chemical additives (e.g., nitrites, dyes, and cyclamate), improper or fraudulent meat inspection or food labeling, microbial epidemics among livestock (e.g., Escherichia coli), food products from diseased animal sources, and disruption of vital natural food chains by ecosystem destruction. Increased mobility and globalized trade also contribute to global contamination of the food supply. Finally, there are significant disparities in access to healthy and fresh food supplies, with poor minority families being more likely to live in a food desert—a neighborhood with little to no access to healthy foods.

Annually, nearly 60 to 70 million Americans contract gastrointestinal illnesses, accounting for about 10% of all hospitalizations and 15% of in-patient hospital procedures for the treatment of digestive diseases. Potential microbial contaminants of foods include bacteria (e.g., Shigella, Salmonella, E. coli, Campylobacter, Listeria), parasites (e.g., Balantidium coli, Cryptosporidium parvum, Entamoeba histolytica, Giardia intestinalis), and viruses (e.g., calicivirus, rotavirus, hepatitis A virus, enterovirus). The federal government utilizes meat inspectors to prevent misbranded meat and meat products from being sold as food and ensure that meat animals are slaughtered and meat products processed under sanitary and humane conditions. The United States currently depends on the Foodborne Diseases Active Surveillance Network (FoodNet) of the C.D.C's Emerging Infections Program to collect data on diseases caused by enteric pathogens transmitted through food. Public health nurses play a key role in foodborne illness investigations.

Food can also be contaminated by agrichemicals, such as pesticides and fertilizers; materials from mechanical handling devices; detergents; and organic packaging materials. Toxic chemicals from farming and ranching may be introduced into the food chain, increasing risk of reproductive and mutagenic effects in humans. For instance, farmers spray dioxin-containing weed killers on rangeland. Beef cattle graze on the land, herbicide accumulates in their fatty tissue, and the contaminated meat is sold in markets. The complexity of transfer of these contaminants makes for difficulty in establishing causality and tracing accountability for these health risks.

Unsuitable handling, storage, processing, and transport techniques can damage food and make it unsuitable for consumption. Nurses can council patients on the proper handling of food (Fig. 14.4). Furthermore, additives are often used to improve food properties. For example, vitamins and minerals are used to enhance nutritional content; salt, sugars, and monosodium glutamate are used to improve flavor; dyes are used to enhance color; leavening agents, gums, or thickening agents are used to improve consistency; and various preservatives are used to increase shelf life. Many of these additives are not nutritious, and some may be harmful. Additionally, residues from the overuse of antibiotics in animal husbandry remain in meat and milk products, causing consumers to develop resistance, thus rendering these antibiotics ineffective in treating human infections.

Figure 14.4 summary: This figure is an infographic consisting of a series of icons. It illustrates the fundamental steps required to maintain food safety, depicting a sequence of actions including cleaning, separating, cooking, and chilling. The figure concludes that following these four distinct stages is essential for ensuring that food is handled and prepared safely to prevent contamination and illness.

Another potential threat related to food quality involves “genetically modified” (G.M) or genetically engineered foods. G.M foods, which have been in existence since the early 1970s, are created by a process in which scientists splice plant or animal genes with particular traits into the D.N.A of other organisms. This technology has contributed to crops and livestock that grow faster, are more resistant to disease and insects, and produce higher yields and greater nutritive value.

Often G.M crops require less water and fertilizer. There is concern that genetic alteration of food is growing despite the fact that the long-term health effects of eating G.M food are unknown. Some believe that allergies and other immunity problems may proliferate because unique antigens are present on G.M proteins, and G.M foods have unpredictable metabolic processes in animals, humans, and plants (Whitney et al., . Although the U.S Department of Agriculture and the U.S. Food and Drug Administration set policy for foods produced from new plant varieties and breeding, a number of groups and organizations have called for greater public awareness of the potential risks of genetically engineered foods and are working to require more stringent testing of them. The American Nurses Association was among several professional groups that developed principles of a healthy and sustainable food system (Box 14.2).

Clinical Example 14.6

A southwestern U.S town with a population of 10,000 has three elementary schools. School nurses at all three schools had an influx of children into their offices one afternoon with complaints of gastrointestinal symptoms. After verifying that this was happening at all three schools, the nurses called the county health department to report possible foodborne illness outbreak.

The county health nurse came out to the schools that afternoon to investigate the foodborne outbreak. She interviewed the school nurses, the affected and unaffected students, and the cafeteria staff.

After having all students in the school fill out a form describing what they had eaten for lunch, the county nurse was able to determine that the chicken salad was the likely source of contamination. The nurses sent the chicken salad as well as samples of all the ingredients in the salad for laboratory testing. Within 2 days, the nurse received confirmation that the chicken salad had been the source of the illness, related to the use of contaminated celery. The nurse then alerted federal officials.

A warning was issued on www.foodsafety.gov to alert officials across the nation. Food inspectors were sent to the factory that prepared and sold the celery. The source of contamination was isolated to three of the five machines used to slice the prepackaged celery.

The factory was temporarily shut down for thorough disinfection. The school and county nurses worked together to assess the outbreak, alert the appropriate officials, and stop the outbreak from spreading. They undoubtedly saved thousands from illness and possibly death.

Waste Management

Waste management entails the handling of waste materials resulting from industry, municipal processes, and human consumption as well as efforts to minimize waste production. Environmental health problems related to waste management include nonbiodegradable plastics, inefficient recycling

Box 14.2 Healthy and Sustainable Food Systems

Health-Promoting

• Supports the physical and mental health of all farmers, workers, and eaters

• Accounts for the public health impacts throughout the entire lifecycle of how food is produced, processed, packaged, labeled, distributed, marketed, consumed, and disposed

Sustainable

• Conserves, protects, and regenerates natural resources, landscapes, and biodiversity

• Meets our current food and nutrition needs without compromising the ability of the system to meet the needs of future generations

Resilient

- Thrives in the face of challenges, such as unpredictable climate, increased pest resistance, and declining, increasingly expensive water and energy supplies

Diverse In

- Size and scale—includes a variable range of food production, transformation, distribution, marketing, consumption, and disposal practices, occurring at different scales, from local and regional to national and global

• Geography—considers geographic differences in natural resources, climate, customs, and heritage

• Culture—appreciates and supports a diversity of cultures, sociodemographics, and lifestyles

• Choice—provides a variety of health-promoting food choices for all

Fair

• Supports fair and just communities and conditions for all farmers, workers, and eaters

• Provides equitable physical access to affordable food that is health promoting and culturally appropriate

Economically Balanced

• Provides economic opportunities that are balanced across geographic regions of the country and at different scales of activity, from local to global, for a diverse range of food system stakeholders

• Affords farmers and workers in all sectors of the system a living wage

Transparent

• Provides opportunities for farmers, workers, and eaters to gain the knowledge necessary to understand how food is produced, transformed, distributed, marketed, consumed, and disposed

• Empowers farmers, workers, and eaters to actively participate in decision-making in all sectors of the system

programs, unlicensed waste dumps, inadequate sewage systems for growing populations, unsafe dumping of industrial toxins, exportation of radioactive medical wastes, illicit dumping (Clinical Example 14.7), and nonenforcement of environmental regulations.

American consumers' increasing trash production and the improper treatment, storage, transport, and disposal of waste are a significant concern. Routinely, commercial and institutional wastes are dumped with household waste in the same municipal incinerator, landfill, or sewer system. These commercial enterprises are generally exempt from the strict waste regulation applied to industry, although they often generate the same hazardous materials. Small businesses such as dry cleaners, photography laboratories, pesticide formulators, construction sites, and car repair shops discard a variety of substances that can cause serious public health problems.

Traditionally, U.S economic development has produced optimal wealth with the assumption that the environmental health consequences would be minor. This notion of sustainable development has proved inadequate, and cumulative hazardous episodes necessitate tough pollution control technologies. The sustainability paradigm has led to a shift from disposing to recycling of biosolids. Biosolids refers to sewage sludge that has been treated for pathogens to meet the regulatory requirements for land application. This has been a cost-effective practice, but more research needs to be conducted on human health risks of biosolid distribution in the ecosystem.

A number of potential health problems are associated with waste management. For example, solid waste landfills accumulate methane gas, a by-product of decomposing organic wastes. Without proper venting, this volatile gas can move through soil and cause fires and explosions in nearby areas.

Waste incineration causes particulate air pollution and is ineffective in the combustion of many materials. Improper design, operation, or location of a waste site causes hazardous substances to spread through air, soil, and water to poison humans, animals, and plant life. Alarmingly, only a small percentage of hazardous waste actually reaches the designated waste sites; much is disposed of in open pits and in bodies of water, with dangerously uncertain long-term effects.

New methods are being developed to estimate long-term rates of leaching of materials in various types of waste sites, based on probability principles.

In 1980, Congress passed the Environmental Response Compensation and Liability Act, which established a revolving fund called the Superfund to clean up several hundred of the worst abandoned chemical waste disposal sites. One of the most notorious sites is the Love Canal in Niagara Falls, New York. For 40 years before the 1960s, more than 80 different types of chemicals, including benzene, dioxin, trichloroethylene, toluene, and chloroform, were dumped in an abandoned canal. Afterward, the covered area became the site for a school and several hundred homes.

In the winters of 1976 and 1977, heavy snowfall and rain caused toxic wastes to reach the surface. Subsequently, the inhabitants experienced elevated miscarriage rates, blood and liver abnormalities, birth defects, and chromosome damage.

Clinical Example 14.7

In a city on the Mississippi River, an outbreak of shigellosis was traced to a group of high school students who had been swimming in a particular area of the river. The local meat-packing plant was releasing waste material, including human and animal feces, directly into the river. After intervening to contain the Shigella outbreak, the local community health nurses began to assess the situation. Their research indicated that the meatpacking facility had been in violation of waste control laws for some time. City officials imposed fines, which the company paid, but the dumping continued.

Signage placed along the riverbanks prohibited swimming. Frustrated by their attempts to negotiate with the city and the plant, the nurses wrote a letter to the state capital newspaper, which had a large state readership. In the letter, they voiced concern about the community's health and the river's ecological integrity.

The paper published their commentary, prompting responses from two local environmental groups, several activist groups, and a national organization concerned with clean water. These groups provided legal support and brought a collective suit against the meatpacking company. Subsequently, the company improved its waste treatment process to avoid legal ramifications.

Genetics in Public Health

The Built Environment

Obesity is a preventable condition, yet worldwide has nearly tripled in the past 4 decades. Obesity and weight gain is linked to genetic disposition but not as an isolated factor. Lifestyle interactions with the built and natural environments are implicated in obesity risk where access to safe and walkable surroundings is not available. Integrating environmental information with genetic characteristics allows for developing better understanding about health outcomes and health behavior (Population Reference Bureau) and identifying risk predictors for obesity and other human conditions.

Effects of Environmental Hazards

Environmental hazards are ubiquitous, and their effects on the public's health are complex and generally interconnected. Nurses must understand the multiple and complex sequences leading to health concerns (Fig. 14.5). For example, nuclear power plant emissions may contaminate water and air supplies, affecting water quality, atmospheric quality, and radiation risk. Overcrowded housing may exacerbate problems in managing human waste, which may taint foodstuffs and contribute to the spread of communicable disease. Climate change continues to affect humans, the food chain, vegetation, and wildlife.

Figure 14.5 summary: This table categorizes various health effects resulting from environmental exposures based on their severity. It distinguishes between less serious conditions, which are characterized as reversible, non-debilitating, and non-life-threatening, and more serious conditions, which are described as irreversible, debilitating, and life-threatening. Examples of less serious effects include mild respiratory issues and general discomfort, while more serious effects include organ damage, cancer, and birth defects.

Effects of environmental hazards may be general or specific. For example, the ramifications of high unemployment, drought, and extensive smog cover affect the public generally. Other environmental health concerns, such as the housing needs of elderly people who use walkers or canes, the occupational risks of electrical line repair workers, and the mentally incapacitating effects of elevated blood lead values in children, affect the public more specifically.

Environmental health effects can be immediate, long-term, or intergenerational. Burns, gunshot wounds, hurricane damage, and outbreaks of gastrointestinal distress among cafeteria customers are examples of immediate effects from health-damaging environments. Examples of long-term health effects include gradual occupational hearing loss, “black lung” in coal miners, and increased rates of thyroid cancer among young victims of the Chernobyl nuclear reactor accident. Intergenerational effects will likely occur with climate change by affecting women of childbearing age.

Certain environmental exposures have been found to have a direct relationship with the development of some cancers, chronic diseases, and other health-related problems. Furthermore, oppressive environments may affect health directly. In one case, an American company dumped dangerous waste material in Mexico rather than pay for proper disposal. Poor children who lived nearby and scavenged for food in the dump picked up and played with the shiny, brightly colored radioactive medical waste. The severe burns they suffered and the wine-colored spots on their skin were direct effects of the illegally dumped toxic waste.

Effects of environmental risks may also be indirect, such as in the case of global warming. Global warming is the gradual increase in the average temperature of earth's near-surface air and oceans since the mid-20th century and its projected continuation. Rising global temperatures may enhance the quantity and distribution of parasites, insects, and other disease vectors, potentially increasing the prevalence of a variety of infectious diseases. For example, global warming contributed to the entry and propagation of the West Nile virus in the United States and is suspected in facilitating the rapid spread of the Zika virus. Higher air and water temperatures facilitate the spread of vectorborne diseases transmitted by mosquitoes (e.g., West Nile virus). As a result, 2012 saw more cases of West Nile virus infection (5387) than any year since 2003, with a higher proportion of deaths (243) (C.D.C, 2012); however, between 2012 and 2015 there has been an annual consecutive reduction in both the number of cases and deaths related to West Nile Virus.

Efforts to Control Environmental Health Problems

The 1970s were the decade of environmental concern. Cynicism toward institutions grew during the years of U.S involvement in Vietnam, and legislative activism for environmental preservation exploded. During the 1970s, Congress created new agencies to regulate environmental conditions on a national level, including the E.P.A, the Occupational Safety and Health Administration, and the Nuclear Regulatory Commission. The E.P.A has enormous responsibilities for protecting the environment and minimizing risks to human health. Among its roles are health surveillance and monitoring; setting standards for air and water quality; evaluating environmental risks; acquiring information; screening new chemicals; performing basic research and training; and establishing, evaluating, and enforcing regulatory efforts.

The legislative activism of the 1970s was aimed toward a comprehensive national environmental policy. For example, stricter automobile fuel and emissions standards created improvements in air quality, which caused lead levels in urban air to decrease dramatically over the next decade. The momentum to control environmental pollution in the United States slowed in the 1980s and 1990s, with several policy reversals and the defunding of regulatory mechanisms. In recent years, administrative and legislative activity related to the environment has focused on such issues as climate change, oil spills, hazardous waste, and toxic exposures.

Frequently, laws and regulatory structures are weak or nonexistent with regard to environmental health problems. For example, federal mandates for recycling do not exist, although local communities have made great strides in this area. Comprehensive groundwater legislation, similar to adopted measures to preserve marine and surface waters, also does not exist. Additionally, the E.P.A tends to set priorities for the reduction of environmental problems but does not allocate the resources necessary to accomplish these goals.

Research Highlights

Emerging Issues in Environmental Health

Within the past decade, we are beginning to recognize that our environmental public health infrastructure is quite weak and that the United States is susceptible to many of the same problems that burden the rest of the world. For example, the illegal use of pesticides, medical waste incineration, and the increased incidence of asthma related to air pollution are just a few of the challenges facing the United States today. The manufacturing of methamphetamine in home-based and mobile laboratories continues to rise, and the “cooking process” emits dangerous levels of toxic chemicals into the air. Similarly, the abandoned labs also pose a threat. Finally, natural disasters and climate change affect the entire world.

Natural disasters can disrupt and oftentimes overwhelm private and public health systems. Natural disasters, such as the tsunami that struck the coast of Indonesia in December 2004, Hurricane Katrina in August 2005, the devastating earthquakes in the Sichuan Province of China in 2008 and in Haiti in 2010, and superstorm Sandy in 2012, require mobilization of disaster relief units that offer substantial assistance and expertise. Natural disasters such as hurricanes, tornadoes, and earthquakes frequently receive notable publicity, but other, more insidious disasters, such as droughts, floods, heat waves, and extreme cold, also pose major public health concerns. All of the aforementioned threats can cause significant mortality and morbidity and therefore have the potential to burden the healthcare delivery system.

Global warming is part of a larger issue called climate change that poses significant health hazards. Climate change is the change in weather over a certain period. Weather patterns are greatly affected by atmospheric and oceanic temperature rises. Climate change projections suggest that heat waves and hot weather are likely to increase in frequency, with the overall temperature distribution shifting away from extreme cold.

I Prepare: Development and Clinical Utility of an Environmental Exposure History Mnemonic

The I Prepare environmental exposure history mnemonic is a quick reference tool created by Paranzino et al. (2005) for primary care providers. A total of 159 healthcare providers, both students and professionals, were asked to evaluate a prototype of the mnemonic, to suggest new health history questions, and to propose the deletion of less relevant questions. The prototype was formatted as a pocket guide.

The goal of this evaluation was to create a practical and clinically relevant mnemonic rather than to obtain quantitative estimates of its validity. This mnemonic is meant to serve as a mental cue to facilitate the collection and documentation of health information in a systematic manner:

- —Investigate Potential Exposures

- P—Present Work

- R—Residence

- E—Environmental Concerns

- P—Past Work

- A—Activities

- R—Referrals and Resources

- E—Educate

Questions to ask are presented for each letter in the mnemonic, except for Referrals and Resources, which provides sources of additional information. A checklist of strategies to prevent or minimize exposures can be used by the healthcare provider to help clients identify potential exposures. The sequence of I Prepare makes intuitive sense by cueing the provider to ask specific questions and then provide educational materials to the client.

The final version was reprinted on heavy laminated material. The I Prepare mnemonic increases the repertoire of tools clinicians have available to elicit an appropriate health history. The national improvements in the quality of environmental exposure history are predicated, in part, on the creation of simple and convenient tools for use in clinical practice.

Most of the U.S environmental health efforts have aimed for short-term results rather than anticipating future issues and problems. A crucial need exists in the development of human resources in the area of environmental health. Nurses in all areas of practice should be aware of the implications of the environment for their clients and their health. It is for this reason that nurses need to take and record an environmental health history for every client.

. Climate change can have severe adverse health effects, such as health-related illness and death; increases in air pollution; water-, food-, vector-, and rodent-borne diseases; malnutrition; contaminated water supply; and injuries and deaths related to extreme weather and storm surges. There are regional differences in the effects of climate change, although vulnerable populations will be affected the most. For instance, climate change will raise the risks of infant and maternal mortality, birth complications, and poorer reproductive health, especially in developing countries.

Nursing Actions

Nurses must work with the public to promote more stringent and actively enforced environmental legislation and regulations. In the 21st century, actions must include not only national but also worldwide environmental policies. Ozone depletion, climate change, fossil fuel burning, marine dumping, abandonment of active land mines in war-torn areas, and destruction of tropical rainforests are among the key global environmental health concerns.

Environmental concerns for clean air, clean water, and freedom from noxious chemicals must become nursing concerns. Community health nurses can be catalysts to neighborhood efforts to produce safe living environments. Community health nursing must expand its theory and practice to incorporate the fact that individual and community health ultimately depends on global environmental integrity.

Many organizations work to preserve and protect the environment and could benefit from the active involvement and support of nurses. Box 14.3 lists some of these organizations. Nursing must include an environmental perspective by committing to environmental health promotion initiatives that promote social justice and environmental responsibility.

Approaching Environmental Health at the Population Level

In the United States, personal independence and individual responsibility for success and failure are valued. These values can lead nurses to overlook environmental hazards and instead blame individual clients for their health problems. Placing responsibility for the cause and cure of health problems exclusively on the individual reinforces the belief that all individuals are free to exert meaningful control over the quality and length of their lives. Such a perspective absolves society, government, industry, and business from accountability.

Research suggests that changing individual behaviors does 'to significant reductions in overall morbidity and absence of basic social, economic, and political ...ham, 2008). Emphasizing only in- ...us personal habits through smoking cessation account the 'ical

Box 14.3 Nongovernmental Environmental Organizations

• Alliance of Nurses for Healthy Environments (http://envirn.org/)

• American Farmland Trust (http://www.farmland.org/)

Citizens for a Better Environment (http://www.cbezambia.org/)

• Clean Water Action (http://www.cleanwateraction.org/)

• Green America (http://www.greenamerica.org/)

• Environmental Defense Fund (http://www.edf.org/)

• Environmental Working Group (http://www.ewg.org/)

Greenpeace (http://www.greenpeace.org/usa/en/)

• International Rivers Network (http://www.internationalrivers.org/)

• National Audubon Society (http://www.audubon.org/)

• National Environmental Law Center (http://www.nelconline.org/)

• National Geographic Society (http://www.nationalgeographic.com/about/)

• Natural Resources Defense Council (http://www.nrdc.org/)

• National Wildlife Federation (http://www.nwf.org/)

• Ocean Alliance (http://www.oceanalliance.org/)

• Pesticide Action Network (http://www.panna.org/)

• Rainforest Action Network (http://ran.org/)

• Sierra Club (http://www.sierraclub.org/)

• The Nature Conservatory (http://www.nature.org/)

• Trust for Public Land (http://www.tpl.org/)

• Wilderness Society (http://wilderness.org/)

• World Wildlife Fund (http://worldwildlife.org/)

degradation. An attempt to build a healthier future for all is the Healthy People 2030 initiative. The Healthy People 2030 box lists selected environmental health objectives of the Healthy People 2030 initiative.

Healthy People 2030

Selected Objectives for Environmental Health

- E.H—1: Reduce the number of days people are exposed to unhealthy air E.H—2: Increase trips to work made by mass transit

- E.H—3: Increase the proportion of people whose water supply meets Safe Drinking Water Act regulations

- E.H—4: Reduce blood lead levels in children aged 1 to 5 years

- E.H—5: Reduce health and environmental risks from hazardous sites

- E.H—6: Reduce the amount of toxic pollutants released into the environment

- E.H—7: Reduce exposure to arsenic

- E.H—8: Reduce exposure to lead

- E.H—9: Reduce exposure to mercury in children

- E.H—10: Reduce exposure to bisphenol A

- E.H—11: Reduce exposure to perchlorate

- E.H—D.0.1: Increase the proportion of schools with policies and practices that promote health and safety

- E.H—D.O.2: Reduce diseases and deaths related to heat

Ethical Insights

Protecting Vulnerable Aggregates

Community health nurses have a mandate to assist vulnerable aggregates who have fewer options in protecting themselves from pollution, inadequate housing, toxic poisoning, unsafe products, and other hazards. Non—English-speaking individuals, children, very low-income women and families, undocumented manual laborers, and people from racial and ethnic minorities are just some of the groups in the United States who hold minimal influence with industry, government, business, and other large institutions for environmental changes and compensations for harm from environmental hazards.

Interventions designed for individuals must consider the environmental determinants of behavior and health outcomes. Community health nurses who base their practices on theory and evidence are better prepared to respond to collective challenges. These nurses can facilitate community participation in identifying and solving environmental health problems and bringing about changes that improve environments and eliminate hazards.

Critical Environmental Health Nursing Practice

The National Center for Environmental Health, the C.D.C, and the American Public Health Association has established three core competencies for environmental health professionals: assessment, management, and communication (Box 14.4). Several clinical examples throughout the chapter illustrate how nurses can focus their efforts by organizing groups of people, taking a stand, and acting as advocates for change. The nurses ask critical questions, stay engaged with the communities they serve, form coalitions, and use various collective strategies. The American Nurses Association highlights 10 critical environmental health principles. In the interest of educating future practitioners about the critical practice of environmental community health nursing, the following sections discuss each of these interventions.

Taking a Stand: Advocating for Change

Nurses must make individual and collective decisions about which interests they want to serve with their specialized knowledge and skills. Nurses may choose to work with vulnerable people or those disproportionately experiencing the consequences of environmental hazards. Vulnerable groups are exposed to more health-damaging effects than less vulnerable groups. Nurses can work toward health equity through the decisions they make, the positions they accept, and the interventions they undertake. Environmental problems are clearly intertwined with social, political, and economic policies; resource barriers; and the interests of those in positions of control. Nurses need to connect the immediate and long-term health problems experienced by particular communities to this larger sphere of influence.

Asking Critical Questions

Community health nurses must also consider the relationships between nonhealth policies and health policies. They should

Box 14.4 Core Environmental Health Competencies

Table 14.4 summary: The table outlines a comprehensive set of professional competencies categorized into three primary domains: assessment, management, and communication, detailing the specific capacities required for environmental health practitioners.

Data from American Public Health Association: Environmental Health Competency Project: draft recommendations for non-technical competencies at the local level, 2013. Available from: apha.org U.R.L ask how policies concerning ecological preservation, energy, housing, immigration, civil rights, crime, nutrition, minimum wage, occupational safety, and defense might affect the health and well-being of people. Addressing critical questions such as who has access to resources in this country and whose interests are served in the existing system provides a way to include social, political, and economic factors in environmental nursing assessments. Box 14.5 provides a sample set of questions that are useful in this endeavor. Nurses can ask these critical questions when approaching environmental health problems.

Box 14.5 Critical Questions About Environmental Health Problems

• What is the problem?

• Who is defining the problem?

• In what terms is the problem described?

• How are others in the situation viewing the problem?

• What is the history of the problem?

• How did things get the way they are?

• What other situations does this problem directly affect?

• Who does the problem affect?

• Whose health is damaged because things are this way?

• Who benefits from the way things are?

• Whose interests do current solutions serve?

• What are the economic inequities in the situation?

• Who has political power in the situation?

• Who knows about the problem?

• Who needs to know more about the problem?

• How effective are current programs, strategies, and policies?

• What are the barriers to solving the problem?

• What strategies may alleviate the problem?

• How successful have these strategies been?

• What existing groups might deal with this problem?

• What resources are needed to solve the problem?

• How accessible are the resources?

• How can nurses evaluate potential solutions?

Facilitating Community Involvement

Approaching community health from a critical perspective requires working to improve health conditions and creating the context in which people can identify health-damaging problems in their environments. One important nursing goal is to help people learn from their own experiences and analyze the world with an intention to change it. It is essential that the affected people participate in the process of identifying and working to solve environmental problems. To foster community-based, active participation, nurses must be prepared to take leadership positions and join in mutual exchanges with community members that consider each person's experience. The nurse's role changes from presenting solutions and directing lifestyle changes to providing support, information, and expertise to assist in meeting the group goals.

Using critical questions, community health nurses can help community members look beyond immediate environmental problems and explore social, cultural, economic, and political circumstances that contribute to them. Nurses can share their knowledge about the scientific basis for health problems, their insights about the historical origins of particular environmental hazards, their technical skills, and their expertise in communicating and organizing. By addressing people's everyday concerns and targeting the problems they identify, nurses situate their efforts in community struggles.

Forming Coalitions

Another very important nursing task that arises from approaching environmental health from a critical perspective involves forming coalitions to produce social change. By initiating dialogue and building a strong base of collective support, nurses join with communities to eliminate hazards and improve public health. Nurses can approach existing community organizations, churches, and family and friendship networks to help mobilize aggregate members who have not previously socialized or acted together. Nurses can then discuss environmental concerns, assess needs, plan actions, secure appropriate resources, and advocate for legislative changes.

Nurses can be instrumental in these efforts by helping community groups make connections with larger, more powerful organizations. Nurses can organize forums whereby community groups meet with scientific experts who can help them gather evidence about health threats, with business managers whose actions impinge on the economic life of the community, with industry leaders whose companies create ecological hazards, and with legislators who can bring community concerns to lawmaking bodies. Using available institutional resources, skills, and knowledge, nurses can also explore what is happening elsewhere.

Making connections with groups in other locales who are struggling for similar environmental changes can enhance collective strength and solidarity. Press releases, media events, interviews, television spots, speeches, newsletters, and leaflets are important means of calling attention to a situation and raising awareness among communities.

Using Collective Strategies

Nurses can use a variety of strategies to intervene at the population level and facilitate improvement in a community's health. Nurses can organize people to change health-damaging environments through combinations of strategies, including building coalitions, providing educational forums, facilitating a community needs assessment, disseminating research, and lobbying for legislative changes.

One collective strategy that is an effective population-level community health nursing intervention is participatory action research (P.A.R). This form of research calls for nurses, community members, and other resource people to work together in identifying health problems, designing the studies, collecting and analyzing the data, disseminating the results, and posing solutions to the problems. In P.A.R applied to environmental health, community health nurses and community members would gather information on suspected environmental hazards, determine their effects on health, and devise a plan of action to mitigate the threat.

Although nurses have not traditionally used all of these collective strategies to intervene in community health matters, environmental hazards are multiplying geometrically, pushing nurses to expand their skills repertoire. Pioneers such as Hollie Shaner, R.N, have embraced that concept and are blazing the path to environmental awareness. In the 1990s, Shaner frequently left her home, where she avidly separated and recycled, to work at a Vermont hospital, where none of the waste was recycled. Shaner was not comfortable throwing everything into a"red bag" and decided that there must be a way to change the environmental unfriendliness of her place of employment. She began voluntarily recycling the hospital's cardboard and then began to recycle the newspapers, glass, and plastics. In addition, she received a grant from the state of Vermont to maximize her efforts in medical waste reduction. The efforts and savings did not go unnoticed by the hospital, as Shaner received a new job title of clinical waste reduction coordinator and saved the hospital $175,000 per year.

Shaner also wrote a book for the American Hospital Association on medical waste management. She quickly realized the negative impact the healthcare industry was having on the environmental health of the communities served. Mercury was being released into the streams from medical waste, and dioxins were being released into the air from medical waste incineration.

From this realization, in 1996, Shaner and a small group of other health professionals launched a campaign to lead the health care industry toward environmental stewardship. This campaign, supported by the American Nurses Association, was named Health Care Without Harm."The goal of the campaign was to reduce the environmental health risks that were being created by the health care industry". The campaign still exists and is building momentum; today there are more than 1000 participating organizations in 52 different countries. In 2015 the 2020 Health Care Climate Challenge was launched, aiming to reduce the healthcare carbon footprint, respond with resiliency to the changing patterns of disease, and lead the way for creating a healthier climate.

Research Highlights

Participatory Action Research

Asthma is a significant public health problem that disproportionately affects preschool-age, low-income children. Indeed, children from low-income families have significantly higher asthma prevalence rates, hospitalization rates, and emergency department visits than children from middle-income and wealthier families. This problem is even more pronounced among children in urban areas.

A team of public health nurses led by Garwick et al. (2010) used P.A.R techniques in working with teachers in an urban Head Start program with multiple sites to address asthma management among the children at their sites. In this project, teachers and managers from 16 Head Start centers were identified to participate in three focus groups. During the focus groups, participants identified asthma management issues and challenges, including undiagnosed and unreported asthma, coordination of asthma care with parents, medication administration issues, and variability among asthma action plans. As a result of the P.A.R, a standardized, comprehensive Head Start asthma action plan was developed that outlined strategies the teachers could use to better manage the problem of asthma among the children.

Case Study Application of the Nursing Process

Air Pollution

In July 2001, the Metro Pulse newspaper reported an extensive air pollution problem in the city of Knoxville, Tennessee. The American Lung Association had recently named Knoxville the ninth most polluted city in the country on the basis of the ozone contamination in the air. The following case study expands on some of the reported facts of the situation to construct hypothetical nursing interventions.

Knoxville's community health nurses and the public health department were aware of increasing rates of asthma in particular neighborhoods. In the wake of alarming newspaper and research articles about the dangerous incidence of air pollution and related asthma, the nurses decided to make the health issues a priority. The community health nurses and several nursing students assigned to their department researched the topics and uncovered the following information.

Asthma has long been recognized as a condition in which an acute respiratory response may follow inhalation of a material to which a person is sensitized. Scientists now know that air pollution can lead to nonspecific generalized inflammation. One study found strong evidence that ozone can cause, as well as exacerbate, asthma. The study found that days with worse A.Q.I values resulted in significantly higher school absences due to respiratory illness, and asthma was more likely to develop in children living in high-ozone communities who actively participated in several outdoor sports than in children in communities not participating in sports.

Indeed, the nation's leading group of pediatricians, the American Academy of Pediatrics (A.A.P), revised its policy statement on outdoor air pollution and the health hazards to children. The A.A.P's Committee on Environmental Health strengthened its warning about the dangers that air pollution poses to children because of the recent studies correlating air pollution with asthma and negative lung growth and function. Estimates are that more than 25 million Americans have asthma, including six million children under the age of 18 (C.D.C, 2021b).

An economically depressed neighborhood in Knoxville, hypothetically called Trent Park, is situated near numerous railways, freeways, and industrial yards. High numbers of African American, Latino, and Southeast Asian residents live in the older homes that line the streets of Trent Park. Isolated by language and economic circumstances, many Trent Park residents do not know they are exposed to these environmental health hazards.

Assessment

Elena Garcia, an 8-year-old girl who lives in Trent Park, presented to the pediatric primary clinic at the health department at 8 a.m. in November. Elena had been diagnosed with asthma 2 months ago and was now in mild respiratory distress. Elena explained to the nurse that she had gone trick-or-treating the night before in her neighborhood. It had turned cold that weekend, and she had also played outside in her neighborhood with friends the day before.

In addition, the child's mother explained that Elena had recently had a respiratory virus. The nurse realized that Elena and her mother both mentioned several factors, such as her playing outside on a cold afternoon/evening in a polluted neighborhood and a respiratory virus, that could have exacerbated her asthma.

At the clinic visit, the nurse assessed the following:

• Elena's heart rate and cardiovascular status

• Elena's pattern of breathing, which includes rate, rhythm, and effort

• Elena's asthma medication history

• Evidence of diaphoresis, papillary dilation, and fear, which are all features of the adrenergic response to hypoxia

• Elena's global central nervous system function, such as alertness, cooperation, and motor activity

• Elena's environmental health assessment

Diagnosis

Individual

• Ineffective respirations related to environmental exposure to air pollution

• Insufficient knowledge related to precipitating factors that can cause/worsen an asthma attack

• Stress related to ongoing fear of daughter's illness

Case Study Application of the Nursing Process—cont'd

Family

• Risk for family crisis related to instability caused by the illness

• Insufficient knowledge related to factors that can cause/worsen an asthma attack

Community

• Risk for increased incidence of asthma due to air pollution

• Inadequate programs for asthma screening

Planning

A plan of care was developed at the individual, family, and community levels. Mutual goal setting and contracting are essential if the outcome is to be optimal.

Individual

Long-Term Goals

• Client will modify outdoor time daily according to the A.Q.I

• Client will reduce exposure to allergy triggers

• Client will avoid secondhand tobacco smoke

• Client will keep pets out of the bedroom

• Client will experience successful maintenance of asthma

Short-Term Goals

Client will report reduced outdoor time on days with poor A.Q.I values

• Client will keep an asthma diary and identify which allergy triggers are problematic

• Client will remain free of acute asthma attacks

Family

Long-Term Goals

• Family will follow the city's daily A.Q.I

• Family will encourage child to stay indoors on days with high pollution levels

• Family will remove as many allergy triggers from home as possible

• Family will enforce the pets-out-of-the-bedroom policy

Family will cope effectively with daughter's asthma

Short-Term Goals

• Family will provide encouragement for client to keep an asthma diary

Community

Long-Term Goals

- Citizens will be involved in decision-making process about proposed activities that could pose an environmental hazard

- Citizens will encourage utility companies, government, and industries to reduce air pollution

- Citizens will be encouraged to use mass transit and carpools to reduce vehicle emissions

Short-Term Goals

- Citizens will be alerted about the air pollution problem in the area.

- Citizens will be educated about the A.Q.I and its implications for outdoor activity

Intervention

Individual

• Identify Trent Park children with asthma and plan follow-up home visits to provide education on basic pathophysiology, symptoms of distress, and environmental controls needed for successful asthma management

Add environmental health assessments to child health assessment protocol

• Coordinate with school nurses to ensure they incorporate similar changes into their health assessment protocols

• Prepare and distribute an educational pamphlet with members of Trent Park that details Trent Park residents' air pollution and asthma risks

• Prepare translations of the pamphlet in languages and reading levels appropriate for Trent Park residents, and mail it to individual households

Family

• Facilitate the formation of a support group for families with children who have asthma

Community

• Initiate an asthma awareness program for Trent Park community members.

• Coordinate with school nurses to implement an asthma awareness program in Trent Park schools.

• Develop an asthma action team consisting of Trent Park community members.

• Encourage nursing students and community health nursing faculty from the local university and college programs to participate.

• Lobby state legislatures, municipal officials, local medical associations, local hospitals, and city clinics regarding the project.

ches, the local nurses association, www.ville School Board to ma screening

• Train action team members on how to conduct Healthy Home assessments.

just in stastes.

• Contact local media (e.g., television, radio, and newspaper) about running a series of stories about Knoxville air pollutants and related asthma risks; supply information and contacts for interviews and photographs.

Evaluation

Individual

• Evaluate the child's and mother's understanding of asthma treatments at follow-up home visits.

• Facilitate the evaluation of ongoing interventions.

• Track the number and their efforts in

• Keep close contact with the school nurses and organize an after-school educational and screening program at schools that are understaffed.

• Ask school nurses to report on the educational sessions' success.

Family

• Document participation levels at educational programs and family training sessions.

• Document ongoing participation in referrals and support groups.

Community

The action team was able to get funding to provide Healthy Home assessments and asthma screening to at-risk youth in Trent Park.

Levels of Prevention

Primary Prevention

Educating the community regarding air pollution and its relationship to asthma.

Secondary Prevention

Screening at-risk populations for asthma.

Tertiary Prevention

Follow-up treatment for people with asthma and reduction of air pollutants in the community environment.

Active Learning

1. Identify a health-related problem associated with some aspect of the environment. It may be a problem in a nearby community, a problem publicized in the media, or a difficulty experienced by a family. Examine the problem using the sample series of critical questions listed in Box 14.5. Without sharing the results, present the problem to the group and ask them to discuss it by responding to the same questions. Were there differences or similarities in the initial results and the group's answers? On what points did everyone agree? Why? What questions caused the most disagreement? Why? Now repeat the entire activity by involving people other than nursing students in the group discussion. How did this discussion compare with the previous discussion and responses?

2. Attend meetings that hold environmental hazard discussions. If meetings or public forums are not available in the vicinity, write for information about the state's actions to fight environmental hazards. The reference librarians at colleges or public libraries can suggest ways of contacting sources and will supply addresses. Organizations that are likely to sponsor forums and provide information include those listed in Box 14.3, the Environmental Protection Agency, the National Institute for Occupational Safety and Health, state and municipal agencies for environmental protection and occupational health, environmental caucuses of political parties, the American Public Health Association, the local public health department, farmers' organizations, and labor unions.

Summary

This chapter provided a glimpse into the complex world of environmental health from a critical community health nursing perspective. The case study and clinical examples illustrate that nurses must evaluate the broader picture in assessing the environmental health status of communities and the vulnerable aggregates within them. In preventing, minimizing, and resolving environmental health problems, nurses must

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3. This chapter described how to use participatory research as an intervention in dealing with ecological hazards. In a group, brainstorm about possibilities for participatory action research (P.A.R) projects in the area. Try to identify examples from a variety of environmental health areas. Be creative in planning. How might a nurse mobilize community support and participation in the research? What groups would be approachable? What critical questions might facilitate dialogue about the problem? What kinds of data could be collected, and how could they be used? How could research results be publicized? What ramifications could the completed study have for community members, other communities in the state, and community health nurses in other locales?

4. Nurses may have to supplement their knowledge of collective strategies by reading books about political action and by learning from community members who are experienced in political organizing. Visit a college or public library to investigate books and journal articles outside the nursing literature. Compile a list of references related to one of these political strategies (e.g., grassroots organizing, legislative lobbying, community education, policy analysis, use of the media, coalition building, citizen surveys, public protest, letter-writing campaigns, or consciousness-raising groups). Exchange reference lists with peers to benefit from their efforts. Then choose one or two books of interest and read them.

recognize patterns, detect subtle changes, identify underlying issues, and work collaboratively with a variety of individuals and groups. In the past, environmental threats to health were usually suspected only when other possible causes of illness were ruled out. Nurses can expect this pattern to change dramatically in the 21st century as environmental health moves increasingly to the forefront of the public health agenda.

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