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Population Health for Nurses

14.1 Understanding Environmental Health

Population Health for Nurses14.1 Understanding Environmental Health

Learning Outcomes

By the end of this section, you should be able to:

  • 14.1.1 Discuss how the environment and human health are linked.
  • 14.1.2 Describe the principles and frameworks used in environmental health.
  • 14.1.3 Explain Nightingale’s environmental theory and its ongoing impact on nursing.

Nearly one-fourth of the worldwide burden of disease could be avoided by creating healthier environments (World Health Organization [WHO], 2023a). The conditions for a healthy environment include clean air, a stable climate, sufficient water, sanitation, safe chemical usage, radiation protection, healthy and safe workplaces, sound agricultural practices, healthy communities and built environments, and preserved nature (WHO, 2023a). Healthy People 2030 includes environmental health, considered a social determinant, as an objective. However, environmental hazards and their impact are not equally distributed, with some communities, such as those with lower-income residents or BIPOC populations, shouldering a disproportionate burden. As discussed in Structural Racism and Systemic Inequities, such communities are more likely to be located in areas with high levels of pollution and hazards, often resulting from discriminatory practices in land use, zoning, and the siting of industrial facilities and waste. Furthermore, these communities may lack or have limited access to resources and political influence to advocate for a healthier environment or mitigate the impact of hazards, leading to an increased risk for numerous adverse health outcomes, including respiratory illnesses, cancer, neurological disorders, and developmental delays.

Nurses are critical for promoting and protecting public health, and knowledge about environmental health is essential to provide optimal, targeted care to populations and individuals. Nurses can identify, prevent, and address environmental health issues, which is particularly important given the increasing impact of environmental hazards on human health.

Linking the Environment and Human Health

Environmental health profoundly influences human health through an intricate relationship and various pathways that shape the well-being of individuals and communities. Industrialized society irresponsibly releases vast amounts of pollutants and toxic waste into the biosphere, alters landscapes, and disrupts global climate, resulting in serious degradation of the Earth’s ecosystems. The consequences of such actions eventually impact human populations’ health and well-being. Air quality, for example, directly affects respiratory health, with exposure to pollutants such as ozone aggravating respiratory illnesses like asthma and COPD. Similarly, water quality is of paramount importance; contaminated water elevates the risk of ingesting harmful chemicals such as lead or the transmission of waterborne diseases. Food production and nutrition depend on the health of soil, water, and air. Food safety is also dependent on environmental health, as contamination during production, processing, and distribution can lead to outbreaks of foodborne illnesses such as salmonellosis. Waste management and sanitation systems are critical to protecting the environment and our health from contamination and diseases such as cholera (CDC, 2022d). Inequities compound the issue, with vulnerable populations disproportionately bearing the burden of environmental hazards due to factors such as proximity to industrial sites.

Climate change, discussed in detail in Environmental Exposure and Health Outcomes, introduces another layer of complexity into the relationship between the environment and human health. More frequent extreme weather events amplify risks to both the environment and human health. For instance, extreme heat events exacerbate respiratory and cardiovascular disorders and can lead to wildfires, which further degrade air quality. Warmer temperatures expand the range of disease-carrying vectors, thereby increasing the prevalence of vector-borne diseases such as Lyme disease, caused by Lyme borreliosis carried by ticks and transmitted directly to humans. Environmental disasters can impact our mental health, leading to disorders such as anxiety, PTSD, and depression.

Addressing environmental health requires collaboration among health providers, scientists, engineers, urban planners, public health professionals, organizations and businesses, and agencies across all levels of government. Improving air quality and air quality standards, ensuring the safety and quality of water sources, providing sufficient waste management and sanitation, promoting green spaces, and adopting sustainable practices are required to safeguard both the environment and the health of populations.

National Center for Environmental Health

This video from the Centers for Disease Control and Prevention (CDC) discusses the role the environment plays in maintaining an individual's overall health and well-being.

Watch the video, and then respond to the following questions.

  1. What are some of the ways that the National Center for Environmental Health is working to improve public health safety?
  2. What are some of the potential health risks associated with environmental exposures?
  3. How can nurses address population health challenges associated with environmental factors such as monitoring chemical exposures and preventing childhood lead poisoning?

Frameworks and Principles of Environmental Health

Environmental health aims to prevent illness, death, and disability by reducing exposure to harmful environmental conditions and promoting behavior change. Human behaviors and interactions with the environment have a significant impact on health, including air and water quality, food safety, management of hazardous waste, and efforts to address climate change. Nurses must be equipped to recognize and manage environmental risks that impact their clients and communities, as these risks can significantly affect health outcomes. The section below discusses frameworks and principles to provide guidelines and strategies for addressing environmental health in clients and populations.

How Does Environment Affect Our Health?

In this video, Mighty Fine of the American Public Health Association explores how the environment affects our health.

Watch the video, and then respond to the following questions.

  1. How did environmental health initiatives in the early 20th century contribute to reducing infectious diseases in the United States? What were some of the key strategies used?
  2. The video highlights the concept of environmental justice. How do environmental hazards disproportionately affect BIPOC populations, low-income areas, and underserved groups?
  3. How does the involvement of local governments differ from national efforts in promoting environmental health? What challenges might local governments face when implementing initiatives to improve environmental health within their communities?

Nightingale’s Environmental Theory

Florence Nightingale was an early advocate for public health and hygiene, her environmental strategy aimed to improve living conditions and prevent the spread of diseases. Nightingale’s Environmental Theory viewed nursing as the process of using the client’s environment to assist them in their recovery (Gilbert, 2020). Observing that many wounded soldiers were dying from preventable diseases during the Crimean War (1853–1856), Nightingale realized that the unsanitary conditions in military hospitals contributed to the high mortality rate. To address this issue, she developed an environmental strategy that focused on fresh air, clean water, sanitation, hygiene, and light (Gilbert, 2020).

Although less well known as a statistician today, Nightingale was the first woman inducted into the renowned Royal Statistical Society. During the Crimean War, she painstakingly collected and analyzed data on the causes of death and mortality rates of soldiers. To effectively communicate her findings, Nightingale developed innovative visualization methods, including the coxcomb, a graphic representation similar to a pie chart, to demonstrate that a substantial proportion of soldier deaths were due to disease, exposure, and infection rather than injuries from battle and were therefore preventable (Figure 14.2).

An example of a coxcomb infographic created by Florence Nightingale.
Figure 14.2 Florence Nightingale created infographics like this coxcomb to easily communicate complex data. (credit: “Diagram of the causes of mortality in the Army in the East” by National Library of Medicine, Public Domain)

Theory in Action

What Would Florence Nightingale Make of Big Data?

This animation discusses the significance of Nightingale’s work on statistics and its lasting impact.

Watch the video, and then respond to the following questions.

  1. How did Nightingale’s background in statistics and her meticulous, data-driven approach impact health care during the Crimean War and after?
  2. Nightingale’s work laid the foundation for modern practices like maintaining cleanliness in health care facilities. In what other ways do you think her principles and methodologies continue to influence modern health care?
  3. Nightingale’s ability to transform data into easily understandable infographics played a significant role in conveying her message to policymakers and the public. How important do you think data visualization is in communicating complex health care information today? How might effective data visualization lead to better health care outcomes?

One Health

The One Health approach (CDC, 2022f) emphasizes the interconnectedness of human health, animal health, and the environment. With growing populations and expanded habitats, closer contact between humans and animals increases disease transmission, while environmental changes and global movements amplify disease spread. These shifts have led to the rise of both known and emerging zoonotic diseases, impacting millions of humans and animals each year. Common One Health issues include emerging zoonotic diseases, antimicrobial resistance, vector-borne diseases, food safety, environmental contamination, and the impacts of climate change. For example, vector-borne diseases such as Lyme, transmitted from ticks to humans, now occur in a wider area as ticks adapt to environmental change. As a result, populations that were previously not at risk of Lyme disease now face increased likelihood of exposure. The CDC uses One Health to monitor and manage public health threats and plan effective public health interventions in collaboration with partners. Ultimately, One Health aims to prevent zoonotic outbreaks, enhance food and water safety and security, mitigate antimicrobial resistance, safeguard global health, and promote biodiversity and conservation. Learn more about One Health in action here.

Upstream vs. Downstream

As introduced in What Is Population Health?, upstream and downstream approaches to health and health care represent different points in the chain of events leading to particular positive or negative health outcomes. Upstream approaches focus on the beginning of the causal pathway by addressing underlying factors, such as the social, economic, and environmental determinants that contribute to health outcomes. Upstream factors are often difficult to see or measure, but they can have a profound impact on human health. For example, programs to reduce poverty or promote sustainable agriculture, campaigns to raise awareness or educate the public on a particular topic, and environmental regulations to reduce pollution are upstream interventions aimed at improving overall health outcomes.

Conversely, downstream factors occur later in the chain of events. These factors are more specific and often relate to individual behaviors and health care delivery systems. Downstream factors are more visible and easier to measure, but they are often the result of upstream factors. Examples of downstream factors in environmental health include individual lifestyle choices and access to medical and preventive care. Interventions using a downstream approach focus on mitigating the immediate effects of health problems, such as screenings, medications, procedures, and individual behavior change programs. While downstream interventions are necessary for treating existing health problems, they often fail to address their root causes and may not lead to long-term improvements in population health. For example, one upstream factor that contributes to air pollution is the burning of fossil fuels, which releases harmful pollutants into the air that cause respiratory problems, heart disease, and cancer. A recent study found that nitrogen oxide, particulate matter, and ozone from U.S. oil and gas production alone resulted in 7,500 additional deaths, 410,000 incidents of asthma attacks, and 2,200 fresh cases of childhood asthma throughout the United States in the year 2016 (Buonocore et al., 2023). An upstream approach would be to control air pollution and reduce exposure. On the other hand, downstream consequences of air pollution include asthma attacks, heart attacks, and premature deaths. Downstream interventions would focus on mitigating the impact of the air pollution by providing treatment for respiratory issues or distributing masks for outdoor use during times when air quality is poor. Addressing upstream factors helps to prevent environmental problems from occurring; addressing downstream factors mitigates the impact of environmental problems.

Environmental Justice

Environmental justice refers to the fair and equitable treatment and meaningful engagement of every individual, irrespective of race, color, national origin, or socioeconomic status, in the development, execution, and enforcement of environmental laws and policies (U.S. Department of Energy, 2023). The goals of environmental justice are to offer equal protection from hazards and to ensure equal involvement of communities in making decisions about policies and regulations that impact them. Advocates of environmental justice aim to ameliorate the disproportionate burden of environmental hazards encountered by certain marginalized and vulnerable populations (Environmental Protection Agency [EPA], 2023j). Environmental justice connects environmental issues with broader social justice concerns, recognizing that environmental degradation often intersects with issues related to health inequities, housing, education, and economic opportunity. As such, advocates seek to foster sustainable and inclusive communities that prioritize the well-being and health of all residents. They work to raise awareness about these issues, mobilize affected communities, and promote policies and practices that prioritize environmental equity and fairness.

The concept of environmental justice emerged in the 1970s in response to environmental issues often faced by low-income communities, BIPOC communities, and other marginalized groups (Lynch et al., 2021). These communities carry a greater burden, with increased exposure to pollution, toxic substances, hazardous waste, and other environmental hazards due to structural factors such as discriminatory land-use policies, socioeconomic disparities, and lack of political power. Examples of environmental justice issues include siting of polluting industries in low-income neighborhoods, lack of access to clean and safe drinking water in certain communities, and unequal enforcement of environmental regulations. For more on these issues, see Structural Racism and Systemic Inequities.

The movement gained momentum in the 1990s, with the term officially recognized in the Presidential Executive Order 12898 in 1994, directing federal agencies to address environmental justice issues in their programs and policies (EPA, 2023a). In 2021, President Biden issued an executive order to initiate Justice40, an environmental justice initiative aiming to address environmental and climate issues while prioritizing equity and justice for disadvantaged communities. The initiative, based on the principle that communities that have been disproportionately harmed by pollution and climate change should be first in line to benefit from the transition to a clean energy economy, commits to investing 40 percent of the overall benefits from federal climate and clean energy programs into these communities (EPA, 2023m). Justice40 represents a significant step toward integrating environmental justice principles into federal climate and environmental policies, with a focus on rectifying historical and systemic disparities in environmental protection and climate action (Exec. Order No. 14008, 2021).

Environmental Health Sciences

Exposure assessment, toxicology, epidemiology, and risk assessment are interconnected approaches that play a vital role in the field of public health and environmental health:

Exposure assessment is a subfield that measures, characterizes, and models the frequency, magnitude, and contact duration of agents with an exposed population. Exposure assessments also evaluate the effectiveness of interventions and provide health professionals with information about the source, routes, and areas of uncertainty to help determine a course of action (CDC, 2022b).

Toxicology examines how harmful natural substances (toxins) or harmful artificial substances (toxicants) affect living organisms. The primary goal of toxicology is to assess the potential risks associated with exposure to various chemicals, including drugs, industrial products and by-products, environmental pollutants, pesticides, minerals, and metals. Toxicologists examine how these substances enter the body; how they are distributed, metabolized, and eliminated; and how they affect both organs and systems. The Agency for Toxic Substances and Disease Registry (ATSDR) develops toxicological profiles for hazardous materials, ranked by frequency, toxicity, and likelihood of human exposure. These “Tox Profiles” are extensively researched and peer reviewed. Nurses can access the current list of 275 substances at the ATSDR’s Substance Priority List.

Environmental epidemiology focuses on the links between environmental exposures and human health outcomes. Environmental epidemiologists identify potential environmental health hazards, quantify risk, and explore how different environmental factors, such as air and water pollution, chemicals, radiation, and climate change, impact health. The findings are used to inform public health policy, protect communities from risk, and develop interventions aimed at reducing exposures and improving population health.

Biomonitoring is a scientific methodology used to assess the presence and concentration of specific substances, such as chemicals and pollutants, in living organisms. Samples of blood, urine, saliva, hair, nails, and more may be utilized. Biomonitoring examines the extent of an individual’s or population’s exposure to environmental agents and uses this data to monitor the accumulation and impact of substances over time, identify potential health risks, inform regulations, and develop targeted interventions. The CDC runs a national biomonitoring program that measures the presence of over 400 chemicals at over 500 laboratories, and the agency has made numerous significant advances in improving population health, including the reduction of exposure to secondhand smoke and lead (CDC, 2022a).

Environmental burden is how public health professionals quantify and compare the impact of environmental risks on a population’s health. Climate change, air, noise, and water pollution are examples of environmental burdens because they have detrimental effects on the ecosystem and human health. This burden can manifest in a variety of ways, including increased rates of illness, disability, and premature death as well as decreased quality of life and productivity. Health indicators such as mortality rates, morbidity rates, and disability-adjusted life years (DALYs) are used to measure the impact of environmental hazards on human health and help identify vulnerable populations at risk. Environmental burden considers the cumulative impacts, or the total harm to humans resulting from the combination and interaction of multiple factors such as pollution, socioeconomics, and preexisting conditions. For example, the impact of respiratory illness on an individual living in a community with elevated air pollution will be greater than that on an individual living in a community with clean air.

Bioaccumulation refers to the gradual accumulation of contaminants, such as heavy metals like mercury and lead, within the tissues of living organisms. This process occurs as organisms consume contaminants from their surrounding environment more rapidly than they are able to eliminate or metabolize them. Instead of being excreted, the substances become stored in the organism’s body, leading to increased concentrations as the toxins accumulate. Over time, organisms higher up the food chain, such as humans, may consume food that contains these accumulated pollutants (EPA, 2021b).

A comprehensive approach is necessary to reduce environmental burden; approaches include addressing the underlying causes of environmental hazards, providing education to the public about hazards, and implementing policies to reduce exposure to environmental pollutants. The C/PHN assesses the reports and then works with regulatory agencies and industries to reduce emissions and waste, advocating for clean energy and transportation and supporting policies that protect vulnerable populations from environmental risks.

Case Reflection

A Home Visit with a Client Who Has COPD

Read the scenario, and then respond to the questions that follow. This case scenario about Mr. Harper will evolve throughout the chapter.

Mr. Harper, a 68-year-old retired miner, has been experiencing increasing difficulty breathing. His health has deteriorated over the past year with two hospitalizations for chronic obstructive pulmonary disease (COPD) exacerbation and recurrent pneumonia. In addition to working in the mines for 44 years, Mr. Harper has a 20-pack/year history of tobacco use and lives alone in an old, damp, poorly ventilated house. His nurse, Regis, is visiting his home for the first time today.

Vital Signs Physical Examination
Temperature: 99.1
  • HEENT: Within normal limits.
  • Cardiovascular: Tachycardic, S1, S2 noted; Regular rhythm; No murmurs or rubs; No jugular vein distention; No edema, 2+ pulses in extremities. Capillary refill > 2 seconds.
  • Respiratory: Bilateral rhonchi and wheezing. Productive cough; thick yellow sputum.
  • GI: Abdomen soft, non-tender, non-distended; bowel sounds normal.
  • GU: Clear urine.
  • Neurological: Presents with occasional confusion.
  • Integumentary: Clean, intact, dry. Complaint of itchiness. Digital clubbing. Cyanosis noted in nail beds.
Blood pressure: 150/95
Heart rate: 104
Respiratory rate: 26
Oxygen saturation: 92% on room air
Table 14.1
  1. What signs and symptoms of COPD exacerbation and pneumonia does Mr. Harper present with?
  2. Identify upstream and downstream factors that could be contributing to Mr. Harper’s deteriorating health.
  3. What immediate actions should Nurse Regis take while in Mr. Harper’s home?

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