Chapter 6Environmental HealthCopyright © 2020 by Elsevier In

Chapter 6
Environmental Health
Copyright © 2020 by Elsevier Inc. All rights reserved.
1
Explain the relationship between the environment and human
health and disease.
Understand the key disciplines that inform nurses’ work in
environmental health.
Apply the nursing process to the practice of environmental
health.
Describe legislative and regulatory policies that have influenced
the impact of the environment on health and disease patterns in
communities.
Objectives
(1 of 2)
2
2
Explain and compare the environmental health roles and skills
for nurses practicing in public health, as well as those
practicing in privacy settings.
Incorporate environmental principles into practice.
Objectives
(2 of 2)

3
3
Physical
Chemical
Biological
Social
Psychosocial
An estimated 24% of the global burden of disease and 23% of
all deaths can be attributed to environmental factors (World
Health Organization [WHO])
Introduction to Environmental Health
4
Besides using these WHO factors, we can also divide and
examine the environment from the perspective of the media in
which environmental degradation takes place: air, water, soil,
and food. And a third approach would be to divide
environmental exposures into categories: biological, chemical,
and radiological.
4
Herbicides
Pesticides
Other chemical carcinogens
Lead
Radiation
Environmental Carcinogens

5
5
Eliminate elevated lead blood levels in children.
Minimize risks posed by hazardous sites.
Reduce significant pesticide exposures.
Reduce the amount of toxic pollutants.
Reduce indoor allergen levels.
Decrease lead-based paint or related hazards.
Healthy People 2020 Objectives for Environmental Health
6
6
Nightingale: clean water and sanitation
Lillian Wald and Henry Street neighborhood
Environmental justice
Extrapolation studies
2001: Centers for Disease Control and Prevention (CDC) begins
biomonitoring
Testing of human fluids and tissues for presence of potentially
toxic chemicals
Historical Context of Environmental Health and Nursing
7
7

Poverty and race
Substandard housing
Hazardous plants and waste sites
Hazardous jobs
Poor nutrition
Less access to health care
Social Determinants of Health and Environmental Justice
8
The term environmental justice refers to the disproportionate
environmental exposures that poor people and people of color
experience in the United States and elsewhere, including lead
paint dust exposure, the presence of pests (resulting in
increased use of pesticides), and the use of supplemental
heating sources that may cause dangerous carbon monoxide
exposure. These combined circumstances multiply the risk for
health disparities.
8
Toxicology
Epidemiology
Geographic information systems
Multidisciplinary approaches
Environmental Health Sciences
9
9
Sometimes called the study of poisons

Negative effects of chemicals
Pollutants have multiple routes into the body Epigenetics:
hazardous changes to DNA
Individuals have unique responses
Chemical “families”
Toxicology
10
Most chemicals cross the placental barrier and can affect the
fetus, just as most chemicals cross the blood-brain barrier. In
addition to direct damage to cells, tissues, organs, and organ
systems, there can be changes to the DNA from chemical
exposures that can change gene expression which, in turn, can
predict disease. This latter effect is the focus of a relatively new
biological study, epigenetics.
10
Studies the strength of association between exposures and
health effects
Uses
Occupational
Environmental
Epidemiologic triangle
Agent
Host
Environment
Epidemiology
11

Epidemiologic triangle is a simple model that belies the often
complex relationships among agent, which may include
chemical mixtures (i.e., more than one agent); host, which may
refer to a community with people of multiple ages, genders,
ethnicities, cultures, and disease states; and environment, which
may include dynamic factors, such as air, water, soil, and food,
as well as temperature, humidity, and wind.
11
Coding data
Relates it to a place on Earth (“mapping”)
GIS community-based maps
Educate communities and local policy makers
Provide graphic depictions of public health (PH) problems
Example
Hill and Butterfield’s model of environmental risks
Geographic Information Systems
12
For example: Nurse researcher Mona Choi used GIS to study the
relationship between air pollution and emergency visits for
cardiovascular and pulmonary diagnosis.
12
Multidisciplinary Approaches
Earth sciences that show how pollutants travel
Geologists
Meteorologists
Physicist
Chemists
Key public health (PH) professionals:
Food safety specialist
Sanitarians

Radiation specialists
Industrial hygienists
13
Earth sciences: Pollutants travel in air, water, and soil.
PH Professionals: We might also add a health educator and
outreach worker to educate the family and encourage
compliance with environmental health behaviors and clinical
treatments. Finally, we may need to work with public health
lawyers to address noncompliance.
13
WHO: “Climate change is a significant and emerging threat to
public health, and changes the way we must look at protecting
vulnerable populations.”
Nurses’ main roles
Mitigation: working at individual, community, institutional, and
governmental level to ensure energy-conserving policies and
practices
Response: public health nurses must be prepared for increased
fire- and storm-related disasters
Climate Change
(1 of 2)
14
There is still much to do to mitigate the steep upward slope now
observed for temperatures, CO2 levels, and sea water levels.
Working at the individual, community, institutional (school,
hospital, and so on), and governmental level, there is much
work to be done to ensure energy conserving policies and
practices, rational transportation practices, and changes in our
consumption patterns.

Regarding response preparation, public health nurses must lead
the development of contingencies for long-term, high heat
weather conditions, as well as increased storm activities (that
include more severe storm patterns) and the associated disaster
preparedness. Nurses should also be prepared for threats to food
security from shifting weather patterns that may not support
food production as usual. And nurses should be prepared for
population migration away from low-lying, coastal regions
creating a new type of refugee migration. The oil spill in the
United States Gulf of Mexico will create an out-migration of
people who can no longer support themselves with their
traditional fishing industries. This type of mobilization will be
typical if the projections for global warming are not reversed.
14
Climate Change
(2 of 2)
Greenhouse gasses
Blanketing effect
Greenhouse effect
15
Risks can be categorized as follows:
Medium: air, water, soil, or food
Type: chemical, biological, or radiological
Setting: urban, rural, or suburban
Functional location: home, school, workplace, or community
Environmental Health Assessments
16

16
National Library of Medicine (NLM)
ToxTown
Household Products page
Environmental pages
Skin deep database
“Right to Know” is an American Nurses Association (ANA)
environmental health principle that recommends access to all
information necessary to make informed decisions to protect our
health.
Information Sources
17
Note that, in both the NLM and the Safe Cosmetic databases,
the information is predicated on what the manufacturers place
on the label as ingredients.
The NLM’s website ToxTown (http://toxtown.nlm.nih.gov/) is
one of the best places to start when developing environmental
assessment skills.
Within ToxTown, there is a new Household Products page
where you can research common products such as personal care
products, cleaning products, pet care products, lawn care
products, and others to see the potential health risks that may be
associated with them.
Skin Deep database (http://www.ewg.org/skindeep) includes
more than 73,000 products that can be searched by brand name
and specific product descriptors. This database provides a
ranking of the health risks.
17

Note the environmental aspects of the problem in every step of
the process:
Assessment
Planning
Intervention
Evaluation
Applying the Nursing Process to Environmental Health
18
Assessment: Use your observational skills (e.g., windshield
surveys); interview community members; ask your individual
clients; and ask the families of your clients. Review Web-based
data on existing exposures, such as air and water pollution
monitoring data, drinking water testing, and contaminated soil.
Relate the disease and the environmental factors in the
diagnosis.
Planning: Look at community policy and laws as methods to
facilitate the care needs for the client; include environmental
health personnel in planning.
Intervention: Coordinate medical, nursing, and public health
actions to meet the client’s needs. Ensure that the affected
person or family is referred for appropriate clinical care.
Evaluation: Examine criteria that include the immediate and
long-term responses of the client as well as the recidivism of
the problem for the client.
18
Use of the “I PREPARE” mnemonic device
Investigate potential exposures
Present work
Residence
Environmental concerns
Past work

Activities
Referrals and resources
Educate
Individual Environmental
Exposure History
19
I—Investigate Potential Exposures
Have you ever felt sick after coming in contact with a chemical,
such as a pesticide or other substances? Do you have any
symptoms that improve when you are away from your home or
work?
P—Present Work
Are you exposed to solvents, dusts, fumes, radiation, loud
noise, pesticides, other chemicals? Do you know where to find
material safety data sheets for chemicals with which you work?
Do you wear PPE? Are work clothes worn home? Do coworkers
have similar health problems?
R—Residence
When was your residence built? What type of heating do you
have? Have you recently remodeled your home? What chemicals
are stored on your property? Where is the source of your
drinking water?
E—Environmental Concerns
Are there environmental concerns in your neighborhood (e.g.,
air, water, soil)? What types of industries or farms are near your
home? Do you live near a hazardous waste site or landfill?
P—Past Work
What are your past work experiences? What job did you have
for the longest period of time? Have you ever been in the
military, worked on a farm, or done volunteer or seasonal work?
A—Activities
What activities and hobbies do you and your family pursue? Do

you burn, solder, or melt any products? Do you garden, fish, or
hunt? Do you eat what you catch or grow? Do you use
pesticides? Do you engage in any alternative healing or cultural
practices?
R—Referrals and Resources
Environmental Protection Agency (www.epa.gov), National
Library of Medicine—Toxnet Programs (www.nlm.nih.gov),
Agency for Toxic Substances and Disease Registry
(www.atsdr.cdc.gov), Association of Occupational and
Environmental Clinics (www.aoec.org). Occupational Safety
and Health Administration (www.osha.gov), EnviRN website
(www.enviRN.umaryland.edu), Local Health Department,
Environmental Agency, Poison Control Center
E—Educate (a checklist)
Are materials available to educate the client? Are alternatives
available to minimize the risk of exposure? Have prevention
strategies been discussed? What is the plan for follow -up?
19
What does the first letter “E” found in the “I PREPARE”
mnemonic device stand for?
Exposure factors
Educational needs
Evidence-based practice
Quick Recall
(1 of 2)
20
20

Answer is C.
Quick Recall
(2 of 2)
21
“I PREPARE” mnemonic device
Investigate potential exposures
Present work
Residence
Past work
Activities
Referrals and resources
Educate
How’d You Do?
22
Windshield survey
“Nature-deficit disorder”
Positive environmental factors
Features that can positively contribute to a community’s health
Green space, bike paths, walkable communities
Community-Wide Environmental Health Assessment Tools
23
A windshield survey is a helpful first step in understanding the

potential environmental health risks in a community.
Urban communities: Note proximity to factories, dump sites,
major transportation routes, and other sources of pollution.
Rural communities: Note if and when there are aerial and other
types of pesticide and herbicide spraying; if people rely on
wood-burning stoves; if there are industrial-type agricultural
practices and/or contaminated waterways.
Nature-deficit disorder was coined by author Richard Louv in
his book Last Child in the Woods to describe what happens to
young people who become disconnected from their natural
world. Louv links this lack of nature to some of the most
disturbing childhood trends, such as the rises in obesity,
attention disorders, and depression.
23
Air
Sources of pollution
Point sources (identifiable—for example, smokestacks)
Non-point sources (mobile—for example, cars and trucks)
Clean Air Act
Indoor air quality (IAQ)
Water
Consumer Confidence Reports (CCRs)
Sources of pollution
Waste from industry, pharmaceuticals
Storm runoff, erosion, especially due to loss of 80% of the
world’s forests leading to massive erosion
Environmental Exposure by Media
(1 of 2)
24

Superfund sites: highly contaminated sites, with associated
health threats that are designated by the EPA
Brownfield sites: land that has been used previously and which
is now slated for redevelopment
24
Land and soil
Contaminated land designations
Superfund site
Highly contaminated
Threat designated by the Environmental Protection Agency
(EPA)
Brownfield site
Previously used
Now slated for redevelopment
Food
Pathogenic causes: Escherichia coli, Salmonella; pesticides;
genetically modified organisms (GMOs)
Environmental causes: pesticides, antibiotics in animals
Environmental Exposure by Media
(2 of 2)
25
Superfund sites: highly contaminated sites, with associated
health threats that are designated by the EPA
Brownfield sites: land that has been used previously and which
is now slated for redevelopment
25
Air Pollution
26

26
Several environmental statutes give the public the right to know
about the hazardous chemicals in the environment.
Health professionals and community members can easily access
key information by zip code regarding major sources of
pollution that are being emitted into the air or water in their
community.
Consumer Confidence Reports
Hazard Communication Standard
Material safety data sheet (MSDS)
Right to Know
27
The EPA has an “Envirofacts” section on its website that
provides several sources of exposure data by zip code.
When a water supplier provides drinking water to a community,
the supplier, in contrast to individual wells, must test the water
and report the results to its customers in the form of a consumer
confidence report. Nurses should review the consumer
confidence reports, sometimes referred to as right to know
reports, to determine what pollutants have been found in the
drinking water.
Hazard Communication Standard: this standard requires
employers (including hospitals) to maintain a list of all of the
hazardous chemicals that are used on-site.
27
Process to determine the probability of a health threat

associated with an exposure
Four phases
Assess toxicology and epidemiologic data.
Has the chemical been released?
How much and by which route of entry of the chemical?
Risk assessment process
Subject to interpretation
Risk Assessment
28
Four phases
Determining whether a chemical is known to be associated with
negative health effects (in animals or humans)
Determining whether the chemical has been released into the
environment: into the air, water, soil, or food
Estimating how much and by which route of entry the chemical
might enter the human body
Characterizing the risk assessment process and taking into
account all three of the previous steps
28
Social determinants contribute to risk levels.
Economic factors: lower income clients are at increased risk for
health problems
Live in substandard housing
Live in close proximity to pollution sources
Employed in more dangerous occupations
Have less access to healthy food options
Life cycle factors
Very young and very old are more vulnerable
EPA report: “Growing Smarter/Living Healthier: A Guide to
Smart Growth and Active Aging”
Vulnerable Populations

29
29
Children’s bodies operate differently than adults, putting them
at potentially increased risk for toxic exposure.
Increased respiratory rate translates to a proportionately gre ater
exposure to air pollutants.
Immature blood-brain barrier
Kidneys less effective at filtering undesirable chemicals
Children’s Environmental Health
30
30
Increasingly difficult to prove specific hypotheses regarding the
relationship of exposure to a singular chemical and disease
outcome in humans
A “precautionary approach” advised when animal research and
other indicators demonstrate a possible toxic relationship
between a chemical and health effect
The Precautionary Principle
31
The American Nurses Association (ANA) has adopted the
precautionary principle as the basic tenet on which to guide its
environmental advocacy work.

31
Apply basic principles of disease prevention.
Prevention is a core goal in PHN.
Every nurse’s role in risk reduction
Shift to e-records to avoid paper
Recycle
Promote minimal packaging and green wrappers
Go fragrance free
Turn off equipment not used
Report dysfunctional plumbing
Promote local sustainable foods (organic)
Start a Green Team
Create community
Environmental Health Risk Reduction
32
Every nurse’s role in environmental risk reduction:
Shift to electronic records, thus avoiding the use of paper.
When paper is a must, use products that are made from recycled
ingredients.
Recycle: paper, glass, cans, plastic, small batteries, blue wrap,
electronic equipment
Work with suppliers to get products with minimum packaging
and the safest ingredients possible— “environmentally
preferable purchasing”
Promote the use of green cleaners.
Go fragrance free—using fragrance-free products in the hospital
and creating a policy that requires employees to use fragrance-
free personal care products (shampoos, creams, etc.)
Turn off lights, computers, patient monitoring equipment when
rooms not used
Report leaky sinks, toilets, and other plumbing sources.

Promote the purchase of local, sustainably grown foods (with a
preference for organic, no use of GMOs, no use of unnecessary
antibiotics, and no pesticides).
Start a hospital/clinic/health department garden.
Start a Green Team, or join the existing one in your institution.
Create community while doing these activities and build
relationships—it makes the whole process more meaningful and
fun!
32
Industrial hygienists: public health specialists
Workplace exposure to hazards that contribute to health risks
Hazards: physical, chemical, and biological
Hierarchy of controls
Three Rs to reduce environmental pollution
Reduce
Reuse
Recycle
Industrial Hygiene
Hierarchy of Controls
33
Industrial hygiene hierarchy of controls
Eliminate unnecessary toxic chemicals.
Substitute less hazardous or non-hazardous substances (e.g.,
using water-based vs. solvent-based products).
Isolate the hazardous chemicals from human exposure (e.g., use
closed systems).
Apply engineering controls (e.g., ventilation systems, including
exhausts hoods).
Reduce the exposures through administrative controls (e.g.,
rotating employees in areas with high exposures).
Use personal protective equipment (e.g., gloves, respirators,

protective clothing).
33
Risk communication includes all the principles of good
communication in general.
It is a combination of the following:
The right information
To the right people
At the right time
Risk Communication
34
Risk communication includes all the principles of good
communication in general. It is a combination of the following:
The right information: Accurate, relevant, in a language that
audiences can understand. A good risk assessment is essential
information for shaping the message.
To the right people: Those affected and those who are worried
but may not be affected. Information on the community is
essential: geographic boundaries, who lives there (i.e.,
demographics), how they obtain information (e.g., flyers,
newspapers, radio, television, word of mouth), where they
congregate (e.g., school, church, community center), and who
within the community can help plan the communication.
At the right time: For timely action or to allay fear.
34
Federal agencies for environmental health regulation
Environmental Protection Agency (EPA), Food and Drug
Administration (FDA), Department of Agriculture
United States Department of Health and Human Services

(USDHHS)
The National Institute for Environmental Sciences (NIEHS),
The National Institute for Occupational Safety and Health
(NIOSH), Centers for Disease Control and Prevention (CDC)
(including the National Center for Environmental Health
(NCEH))
Important steps and concepts
Permitting
Environmental standards
Compliance
Monitoring
Governmental Environmental Protection
35
An important step in the process of controlling pollution is
permitting, a process by which the government places limits on
the amount of pollution emitted into the air or water. A permit
is a legally binding document.
Environmental standards may describe a permitted level of
emissions, a maximum contaminant level (MCL), an action level
for environmental cleanup, or a risk-based calculation;
environmental standards are required to address health risks. It
is the responsibility of potential polluters to operate within the
regulations and standards. Compliance and enforcement are the
next building blocks in controlling pollution. Compliance refers
to the processes for ensuring that permit/standard/regulatory
requirements are met. Clean up or remediation of environmental
damage is another control step. Public information and
involvement processes, such as citizen advisory panels or
community forums, are integral to the development of
standards, ongoing monitoring, and remediation.
35

Nurses can guide and drive policy.
1 in every 100 Americans is a registered nurse!
Nurses have a responsibility to be informed and take action in
the best interest of public.
Nurses can serve as resources for state and federal legislators
and staff.
Nurses also work as advocates for environmental justice and
rights of others.
2008—Alliance of Nurses for Healthy Environments
Created to coalesce nurses and nursing organizations around
relevant issues
Policy and Advocacy
36
36
Certain environmental health risks disproportionately affect
poor people and people of color in the United States.
1993: Environmental Justice Act was passed
1994: Executive Order 12898, “Federal Actions to Address
Environmental Justice in Minority Populations”
Environmental Justice and
Environmental Health Disparities
37
If you are a poor person of color,
More likely to live near a hazardous waste site or an incinerator
More likely to have children who are lead poisoned
More likely to have children with asthma
37

Methylmercury exposure
Persistent Bioaccumulative toxins (PBTs)
Chemicals that do not decompose
Also referred to as persistent organic pollutants (POPs)
Dioxin
Pollutant created by health care industry
Created by incineration of chlorine
Health care without harm
ANA was a founding member of this campaign.
Environmental Health Threats From the Health Care Industry
38
Mercury:
Mercury thermometers and sphygmomanometers
Hospitals that use incinerators to dispose of waste
Synthetic chemicals
Persistent bioaccumulative toxins (PBTs) or persistent organic
pollutants (POPs)
These are chemicals that do not break down in air, water, or
soil, or in the plant, animal, and human bodies to which they
may be passed.
An international campaign called Health Care Without Harm is
working to reduce and eliminate mercury and polyvinyl chloride
(PVC) plastic in the health care industry, as well as the
elimination of incineration of medical waste. The American
Nurses Association (ANA) was a founder of the Health Care
Without Harm campaign, and nurses have taken many leadership
roles in the activities in the United States and around the world.
The Health Care Without Harm website
(http://www.noharm.org) and the ANA’s website
(http://www.nursingworld.org/rnnoharm/) provide outstanding

information and resources about pollution prevention in the
health care sector.
38
National Library of Medicine’s ToxTown
EPA (www.epa.gov)
Environmental epidemiology unit or toxicology unit of the state
health department
Association of Occupational and Environmental Clinics
(www.aoec.org)
Pediatric Environmental Health Specialty Units (10 of these in
the United States)
Poison control centers
Agricultural extension offices
Referral Resources
39
39
Community involvement/public participation
Individual and population risk assessment
Risk communication
Epidemiologic investigations
Policy development
Roles for Nurses in
Environmental Health
40
As nurses learn more about the environment, opportuni ties for

integration into their practice, education programs, research,
advocacy, and policy work will become evident and will evolve.
Opportunities abound for those pioneering spirits within the
nursing profession who are dedicated to creating healthier
environments for their clients and communities.
40

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