Public Health Nursing Foundations PDF

**[Chapter 1: Foundations of Public Health Nursing]** **Public Health Intervention Wheel** - Population based model that is applied to individuals/families, communities or within systems and defines 17 public health interventions focusing upon prevention - Defines scope of practice fo...

**[Chapter 1: Foundations of Public Health Nursing]** **Public Health Intervention Wheel** - Population based model that is applied to individuals/families, communities or within systems and defines 17 public health interventions focusing upon prevention - Defines scope of practice for public health nursing - Red -- Surveillance and disease monitoring - Green -- Case Management - Blue -- Healthcare teaching and counseling - Orange -- Collaboration with community and organizations - Yellow -- Advocacy and policy development and enforcement **Public Health Nursing Definition, Principles, and Responsibilities** - Definition: Population-based practice, which includes assessment, planning, and evaluation at the population level - A synthesis of nursing and public health within the context of preventing disease and disability and promoting and protecting the health of the entire community - Intertwining of nursing, public health, and social sciences with a focus on "the practice of promoting and protecting the health of populations" - Healthful Communities: The PHN is interested in promoting health and education - Population Focused -- Means that care is aimed at improving the health of one or more populations - **Focuses on population health** through continuous surveillance and assessment of the multiple determinants of health with the intent to **promote health and wellness**, **prevent disease, disability and premature death**, and to **improve community and neighborhood quality of life** - Principles: - Client or the unit of care is the population - Primary obligation is to achieve the greatest good for the greatest number of people or people as a whole - Public health nurses collaborate with the client as an equal partner - Primary prevention is the priority in selecting appropriate activities - Public health nursing focuses on strategies that create healthy environment, social, and economic conditions in which populations may thrive - Focus on prevention - Collaboration with other professions, populations, organizations and stakeholder groups is the most effective way to promote and protect health of people - Assists with others to uncover abilities, strengths and spirit - Possibilities and opportunities revealed by fostering hope - Responsibilities: - Providing quality care and teaching - Maintaining healthful environments - Preventing abuse - Advocating for adequate standards of living - Identifying needs and referring for services - Professional development - Collaborating with other disciplines - Ensuring quality of care **Pioneers of Public Health Nursing:** - **Clara Barton:** Cared for wounded soldiers by distributing supplies and caring for the casualties with the help of her team of nurses; founded the American Red Cross - **Florence Nightingale:** Established sanitary nursing care units. Opened the first school of nursing and is considered the founder of modern nursing. Documented her successes saving lives through prevention of infections and improving environmental conditions. - **Lillian Wald:** She found that urban tenement houses in large American cities across the country were crowded and unsanitary, infectious diseases such as TB, typhoid fever, small pox and scarlet fever were present -- coined the term for public health nursing. Founded Henry Street Settlement & Visiting Nurse Service of NYC and taught the importance of health and hygiene. She started first public health nursing (brought healthcare into people's homes), advocated for working conditions/minimum wage for women, and helped with the Spanish flu - **Mary Breckinridge:** Traveling on horseback, she studied the health needs of mountain people and found women lacked prenatal care. Realized that children's healthcare must begin before birth with care of the mother and continue throughout childhood. She founded the Frontier Nursing Service in 1925 **Concepts: Social Determinants of Health, Health Disparities, Epidemiology** - Social Determinants of Health: Conditions in the environmental in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks - These circumstances are shaped by social norms, social and economic policies, and political systems that affect the distribution of money, power, and resources - SDOH Examples: Income, education quality, employment options, job security, working life conditions, neighborhood conditions, food security, housing, social norms and attitudes, discrimination and structural racism, early childhood development, access to affordable quality healthcare - Health Disparities: Differences in healthcare and health outcomes experienced by one population compared with another, frequently associated with race/ethnicity and socioeconomic status - Epidemiology: Study of the distribution and determinants of states of health and illness in human populations; used both as research methodology to study states of health and illness and as knowledge **How Does the Government Monitor the Health of the Population?** - Reviewing hospital admissions (hospital has access to Medicare and Medicaid claims) - Surveys (i.e., behavioral risk factor) - Benchmarks (i.e., quality assurance) - Might get information on office visits - Mortality and morbidity rates (what are people dying from? How old are they? -- county and state) - Cancer - General hospitalizations - Infectious disease numbers (i.e., monitor waste water) **[Chapter 11: Community Assessment]** **Community Assessment** - Assessment is the first step of the nursing process. It allows the nurse to experience what it is like to be in the community, to get to know its people and their strengths and problems, and to work with them to plan and implement programs to meet their unique needs - "How healthy is this community? What are its strengths, problems and concerns?" How Does a Nurse Get to Know a Community? - Objective Data: - Read about a community through newspapers, history, objective statistical reports (census data, poverty rates, unemployment rates, graduation rates etc.) - Check social media sites for community programs or information (community forums, library websites, police department, fire department, EMS agencies) - Subjective Data: - Visit the community, talk to the people, attend meetings, *be with* the people. - Going to the community provides a *feel* for the community that cannot be obtained from just reading about it - What is life like for the residents who live here? Would you like to live here? - Windshield Survey: Subjective observation of a community while driving a car or riding public transportation to collect data for a community assessment. ("learning about the community on foot") - No stats or quantitative data -- Use all 5 senses to get a feel for the community by walking or driving around the community - Interviews with Key Informants: Key informants are people in the community or leaders of the community. Speaking with people in the community is the richest source of information. Can provide health status, interests, community problems and possible solutions - Interviews can be open-ended or formally structured - Community Forums are cost-efficient ways of obtaining opinions about the needs of community members (e.g. town meetings) - Focus-groups are conversations held with a smaller group of people (usually 5 to 10) to identify different perceptions and experiences about a subject Considerations for Assessment: - Health Services: - What health facilities are available in the community? For adults? For pediatrics? Pregnancy? Dental care? Primary/ preventive care? Mental Health? Substance abuse/detox? - Where is the closest hospital? What specialty services do they have? - Ambulance services (EMS)/ Fire Department: Websites may have number of calls, location of fire houses, community programs for elderly and children - Are there are local facilities for uninsured or underinsured to receive health care? Non-English speaking residents? Immigrants? - Are there library programs for health topics? Mental health support groups? - Stores: - Grocery stores: Do residents have access to healthy food? What is available in the community? Is it walkable? - Restaurants/ Fast food: What is available? - Smoke shops - Pawn shops - Check-cashing shops - Law Enforcement: - Where is the closes police precinct? Did you see police cars patrolling during your windshield survey? Check their website or social media for information about community programs for adults and children - Transportation: - Bus service: Approximately where are the bus routes? Is it affordable? What's the price per ticket? - Train: Where is the closest train station? What are the fees to travel into NYC? Drive past the train station- what does it look like? - Pedestrians: Are the roads walkable? Condition of sidewalks? Are the streets well light? - Homeless: - Are there any homeless shelters or food pantries? Check local churches or community organizations. **Community Diagnosis:** - Analyze the community assessments and data collected - Compare your statistics with other similar communities - Identify problems and state them in the form of a community health diagnosis - For example: - Risk of (a specific problem or health risk in the community) - Among (the specific group or population that is affected by the problem or risk) - Related to (strengths and weaknesses in the community that influence the specific problem or health risk in the community) - Examples: - Risk for increased risk of pregnancy among teens at Johnson High School related to increased sexual activity and nonuse of contraceptive services and methods - Risk of lung infections among disaster workers related to debris from Hurricane Katrina recovery - Risk for eating disorders among professional ballet dancers related to occupational pressure to stay underweight for professional advancement **Community Planning:** - Establish priorities, goals and objectives - Goals are broad and general statements of concern that are usually considered long range - Objectives are specific, measurable statements of desired outcomes and are often viewed short term - Prioritize which problem to tackle first. There are usually more than one - Suggested criteria for selecting a health problem for community intervention: - Significance of the problem (in terms of numbers affected or consequences) - Level of community awareness and priority - Ability to reduce risk - Cost of reducing risk - Ability to identify target population - Availability of resources to intervene and reduce risk **Community Implementation:** - This is the action phase - Collaborate with leaders, organizations & professionals - It is better to educate the community to implement the strategies rather than the nurse and other team members controlling the implementation - Plan a trial run of the implementation and obtain feedback so that you can correct any flaws or obtain more resources if needed **[Chapter 5: Levels of Prevention]** **Levels of Prevention:** - Prevention activities eradicate, eliminate, or reduce the impact of disease and injury - Disease includes chronic conditions, communicable and noncommunicable conditions ***Primary Prevention*:** Maximize health and wellness through strategies before illness or injury is present - Prevention of disease and injury before it occurs - Reduction or modifying risk factors - Examples include use of seatbelts, immunizations, handwashing, proper prep of food, exercise, balanced nutrition - There are situations where disease or injury is unavoidable (genetic conditions, unexpected natural disasters) ***Secondary Prevention* (Health Screenings):** Early detection and intervention - Planned effort to minimize impact of disease or injury once it\'s in effect - Screening, diagnosis and early treatment - Initial recognition of the stage of an illness - A screening program is not a substitute for ongoing healthcare with a provider - Effective Screenings Should Be: Cost-effective, easy to use, available to large sectors of the population at risk, sensitive and specific enough to identify true positives/negatives, backed by healthcare structure (need to have a place to send them), and acceptable to clients - Screenings recommended for - Lung Cancer (most deaths per year) - Who should be screened? People who smoke now or who have quit within the past 15 years and are between 50 and 80 years old - What is the screening test? Low dose CT scan - Colon Cancer - Who should be screened? Adults age 45 to 75 years of age; increased risk for those with IBD (Crohn's or ulcerative colitis) - What is the screening test? At home stool test, flexible sigmoidoscopy, colonoscopy - Breast Cancer (most new cases per year) - Who should be screened? Women with average risk of breast cancer; ages 40-44 first screening; ages 45-54 annual screenings; ages older than or greater than 55 annual or every other year screening - What is the screening test? Mammograms (low dose x-ray of breast); breast MRI (women at high risk only) - Prostate Cancer - Who should be screened? Men ages 55 to 69; men older than 70 screening not recommended - What is the screening test? Digital rectal exam; prostate-specific antigen test (PSA) - Screening programs are for high-risk individuals without symptoms ***Tertiary Prevention*:** Correction and prevention of deterioration of a disease state - Long term management and treatment of clients with chronic conditions - Includes disease management, rehabilitation, and palliative care **Multiphasic Screenings, Sensitivity, Specificity** - **Multiphasic Screening**: A variety of screening tests applied to the same population on the same occasion. Data can be used for establishing baseline data in a healthcare facility and for risk factor appraisal - Series of tests performed on a single blood sample - Periodic surveillance of drug therapy - Monitoring the stage of an illness - Case finding: clinician's search for illness in a client's routine health examination - Monitoring the health of individuals in a case load - Mass Screening: Applied to entire populations - Blood lead level screening - Pap smears - Phenylketonuria of newborns - Selective Screening: Performed for specific high-risk populations - Mammography for young women at risk for cancer - Tuberculin tests for hospital employees - Occupational diseases - Exposure to radiation - Sensitivity and specificity are criteria used to measure how valid and reliable a screening test can be - A screening test needs to be confirmed - Nurses should be aware of screening test limitations and economic and psychological costs (fear/anxiety) of false positives - **Sensitivity**: Testing correctly to identify persons who have the disease/physical challenge (looks at positives) - High Sensitivity: True positive (people who have the disease and test positive) - Low Sensitivity: False negative (People who have the disease but test negative \[normal) - **Specificity**: Testing to identify people who don\'t have the disease (looks at negatives) - High Specificity: True negative (people who do not have the disease and test negative) - Low Specificity: False positive (people who do not have the disease but test positive \[abnormal\]) **[Chapter 5: Frameworks for Health Promotion, Disease Prevention, and Risk Reduction]** **Behavior Change Models:** - **Behavior Change Models** (or theoretical frameworks): Describe, explain, or predict healthy behaviors - These are published by researchers after their studies demonstrated the factors related to changing health-related behaviors - These models can help nurses consider creative ways to implement health promotion - Health and well-being for individuals, communities and families is subjective - **Health Belief Model:** - States that developing healthy behaviors is related to: - Severity of the potential illness or physical challenge (how severe is the disease that I might get?) -- Severity is subjective - Level of conceivable susceptibility (am I really going to get it?) - Benefits of taking preventive action (will the healthy behavior really help me?) - Challenges that may be faced in taking action (how difficult will it be for me to start this healthy behavior?) - Uses cues to promote the healthy behavior (i.e., reminder notes in the kitchen about eating healthy, planning among families for "television-free" nights, or billboards in the community about healthy diets) - There is a belief that healthy behaviors can be accomplished (if a community doesn't feel safe walking, then a billboard about walking groups will be unsuccessful) - Age-specific considerations are important (generally, older adults are more frightened than younger adults about susceptibility to chronic disease) - **Transtheoretical Model:** Asks the question "is the individual/family/community ready for behavior change? - Includes 5 stages to determine if the client is ready to change behaviors - Precontemplation: "Not ready" -- People do not intend to change behaviors in the next 6 months. Often underestimate the pros of changing behaviors and overestimate the cons - Contemplation: "Getting ready" -- Intend to change behavior in the next 6 months. Recognize both pros and cons. May still be ambivalent about change - Preparation: "Ready" -- Ready to change in the next six months. Start to take small steps. They believe healthy behavior can lead to healthier life - Action: Recently changed behavior and intend to keep moving forward with the behavior change - Maintenance: Sustained behavior change for over 6 months. Work to prevent relapse - Relapse: Return from action or maintenance to an earlier stage - Experts believe these stages are not linear and people may go through them in a back-and-forth manner - People do not change behaviors quickly and decisively (i.e., deciding to quit smoking) - Nurses should develop interventions tailored to client's level of readiness - **Theory of Reasoned Action:** States that behavior change is determined by a person's intention to perform that behavior - Intention is determined by: - *Attitudes* about the healthy behavior (beliefs on the outcomes of the behavior and value of these outcomes) - i.e., Will eating more fruits and vegetables really prevent obesity and how important is it to have a normal weight? - *Influence* of the person's peers or social/subjective norms (beliefs about what others think they should do) - i.e., What do my friends and family think about this healthy behavior? **Health Literacy Concept and Best Practices** - Health literacy -- The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate decisions - Health literacy includes: - Reading prescription medication labels - Following a childhood immunization schedule - Understanding critically important warnings on the label of an over-the-counter medication - Understanding insurance forms - Reading disease-specific pamphlets - Understanding chronic disease management - Low health literacy is linked to poor health outcomes and health disparities, while high health literacy is connected with good outcomes - Limited health literacy can affect anyone and crosses gender, age, race, ethnicity, and socioeconomic status - These groups are at increased risk: Adults over 65, individuals with limited education or low income, non-native speakers of English, racial and ethnic minorities, recent refugees and immigrants, adults with any type of disability/difficulty or illness - Health Literacy Universal Precautions: Health care providers make all health information easier to understand, confirm everyone\'s comprehension and reduce the difficulty of health-related tasks - Best practices include: - Avoid using medical terms in written/oral communication, when unavoidable clearly define in layman's terms - Use teach-back/show-me method to assess understanding and ability, correct misunderstandings of taught/shared material - Invite questions from patients using patient-centered approach (e.g., what questions do you have for me NOT do you have any questions) - Uses health literacy universal precautions method in written and verbal communication with all patients - Uses professional medical interpreter when communicating with a patient whose preferred language is other than English - Partners with the patient from the beginning of encounter to create a mutual plan of action - Prioritize health messages/teaching with emphasis on 1-3 "need to know" or "need to do" concepts during the clinical encounter - At start of clinical encounter ask patient to share all of their concerns **[Chapter 12: Care Management, Case Management, and Home Care]** **Benefits of Home Care Visits:** - Families with Children: - Home care visits during prenatal and infancy periods prevent development of health problems - Families that received home care visits had fewer instances of child abuse and neglect, emergency department visits, injuries, and poisonings during the first year of life - Infectious Disease: - Home care visits can reduce the incidence of drug-resistant tuberculosis and decrease preventable deaths among infected individuals - Chronic Disease Management: - Conditions frequently cared for in home: diabetes, CHF, incontinence, HTN - Multi-disciplinary teams manage disease and prevent falls - Home care visits can reduce acute ED visits and hospital use - Mental Health: - Community mental health professionals began to include family members and relatives to provide critical support for persons living with mental illness after deinstitutionalization of mentally ill - Hospice Care: - The importance of family focus during the process of end-of-life for family members **Advantages of Home Care Visits:** - More opportunity for individualized care - Can observe environmental factors that impact health (housing conditions) - Family-focused care and participation of family is facilitated - Patient and family may be less anxious in their own environment -- may be more receptive to learning - Care in home reduces overall costs of healthcare by preventing hospitalizations and shortening hospital length-of-stay **Disadvantages of Home Care:** - Travel time for nurses can be costly - Home visits are less efficient for nurses - Distractions such as tv, noisy children can be difficult to control - Clients may be resistant or fearful of bringing people into their home - Nurse safety can be an issue **Bag Technique:** - Place the hand-carried bag on a clean, dry surface or keep the rolling bag on the floor - Perform hand hygiene - Remove the supplies from the bag and place them on a clean, dry surface or on a surface barrier as needed - Do not reenter the bag with gloves on. Remove the gloves if worn, perform hand hygiene, and then reenter the bag - Clean the environment and supplies that had direct patient or environmental contact as needed - Remove PPE if worm, and perform hand hygiene **Hospice Patients -- Common Symptoms:** - Fatigue - Dyspnea - Pain (assess onset, provoking factors, quality, region/radiation, severity, time) - Nausea/vomiting - Diarrhea/constipation - Psychological: Depression, anxiety, delirium **[Chapter 22: School Health Nursing]** **Role of the School Nurse:** - Provide a critical link between the child, the family, and the education and healthcare system - Each state has its own nurse practice act that regulates the profession, including school nursing - National Association of School Nurses (NASN) and American Nurses Association defines the practice of school nurses - Health Assessment - Individual/Population: - Acute illness (vomiting, fever, headache, injury, acute allergy) - Screenings (vision/hearing, scoliosis, BMI, immunizations) - Counseling (students seek advice and support) - Need to differentiate among those that need to go home or those that can stay in school - Need to differentiate between active lice infection or dandruff/dry scalp - Rarely need it, but need to be proficient at recognizing and treating anaphylaxis, cardiac arrest, airway obstruction, active bleeding, or traumatic brain injury - Health promotion (School Health Index collection tool -- helps identify strengths and weaknesses of health and safety programs and help develop action plan) - School health needs - Health educator - Emergency preparedness (School Emergency Triage Training (SETT)) - Chronic Absenteeism -- Evidence-based indicator of children at risk, not just of academic failure, but other social, emotional, or physical health concerns and health inequities **IEP Plan, WSCC Model for School Nursing, School Health Index Collection Tool** - **Individual Education Plan (IEP)** -- Also known as 504 plan -- Developed by an interdisciplinary team to provide education and services to any student that has an identified disability to correspond with individual needs in the least restrictive environment - The school nurse is an integral member of an IEP - IEP -- Any kids that would be applicable to services in school (might be occupational or physical therapy) - **Whole School, Whole Community, Whole Child (WSCC) Model** - Health education, alone, has minimal effect on common health problems. WSCC is a comprehensive design that links the community and the school. It is the future of school nursing and a prevention framework. - WSCC uses the resources of a community to provide structured preventive services such as after‐school programs, parent outreach, and crisis intervention - Components: - Physical education and physical activity - Nutrition environment and services - Health education - Social and emotional climate - Physical environment - Health services - Counseling, psychological, and social services - Employee wellness - Community involvement - Family engagement - Model encourages: - Students and families to be active in their own learning and health - Community agencies and groups to collaborate with school leaders and provide valuable resources for students' health and learning - Schools to support families in promoting healthy behaviors at home, in school, in out-of-school programs, and in the community - Schools, students, and their families to volunteer for community service and open their school facilities to the community for activities promoting health and learning - **School Health Index Collection Tool** - Helps identify strengths and weaknesses of health and safety programs and help develop action plan **Americans with Disabilities Act** - Wide-ranging federal legislation enacted in 1990 that is intended to make American society more accessible to people with disabilities **[Chapter 3: Health Policy, Politics and Reform]** **Medicare** - Medicare is a federal health insurance program for people who are: - 65 Years old or older - Disabled and received 24 months of Social Security Disability payments - Diagnosed with End-Stage Renal Disease (ESRD) - ALS (Lou Gehrig's Disease) - Since Medicare is a federal program, coverage will be the same no matter what state you live in - Medicare Parts: - Part A: Hospital Coverage - Most people do not pay for this - Covers inpatient care, skilled nursing facilities, hospice and some home care visits - Part B: Medical Insurance - Most people do pay a monthly premium for this - Covers MD visits, outpatient care, PT/ OT - Part D: Prescription Drug Coverage - Monthly premium for medications **Medicaid** - Medicaid is a joint Federal and State program to cover medical costs for people with limited income and resources - Federal government has general rules, but each state runs its own Medicaid program. This means that eligibility requirements and benefits vary by state. - New York State Medicaid Eligibility: - Immigration Status -- Must be a US Citizen or meet immigration status requirements - Undocumented immigrants under age 65 are eligible only for emergency treatment of medical conditions, children under 19 are eligible for Child Health Plus - Undocumented adults age [\>]65 years are eligible for Medicaid - Pregnant undocumented individuals are eligible during their pregnancy and one year after delivery - Income -- Meet certain income eligibility tied to household size **Steps of Policy-Making** - ***Problem Identification*** -- Defining problems that are worthy of action - Nurses can define the prevalence of disease, gather case studies, significance of the problem and impact of public health problems - ***Agenda Setting*** -- Capture the attention of policymakers and motivate them to work toward a policy solution - Gain media attention, public support, and stakeholder interest so that your problem gets placed on the agenda for discussion - \*\*Help others view your problem with urgency. Goal is to establish consensus and willingness to work together. - ***Policy Formulation*** -- Development of policy proposal by stakeholders and interest groups occurs in this stage - Decisions are made to shape the policy - Will it be a broad or narrow policy? Who will benefit? Is anyone disadvantaged by the policy? - Nursing testing interventions may use their results to describe how it could be implemented on a larger scale - ***Policy Legitimation*** -- Policy is enacted by a governing body - Federal policy is enacted by acts of Congress (passing a law), executive action from the President or court action - Also involves motivating policymakers to act. - Similar processes occur at the state level - Nurses can act as advocates and contact a legislator about a specific act. - ***Policy Implementation*** -- The policy is put into action - This might involve creating new regulations to put the law into place, building physical space, hiring people to do new work, implementing processes, spending money, and enforcing laws - ***Policy Evaluation*** -- Evaluation involves assessing the extent to which a policy successfully improves the problem it was designed to fix - Policy evaluation can be conducted by the government, researchers, the media, and others. Evaluation may also describe unintended consequences from the policy **[Chapter 13: Family Assessment]** **Calgary Family Intervention Model** - Focuses on enhancing, improving, and sustaining family functioning by focusing on family strengths and resiliency - Cognitive Domain: New knowledge about a health problem affecting the family - Affective Domain: Emotional changes (reduce emotions that are interfering with family's ability to problem solve, cope or heal or the need to increase emotions that support family functioning within the illness experience) - Behavioral Domain: Change behaviors (promote healthy coping mechanisms) **Calgary Family Assessment Model** - Assists nurses in performing a family assessment in an organized systematic manner - Structural Assessment: Genogram / Ecomaps - Functional Assessment: Instrumental and Expressive - Instrumental -- ADLs (what is their routine and rituals) - The nurse assesses the routines, patterns, behaviors, and interactions related to typical daily activities. During the assessment, the nurse is identifying who is responsible for certain tasks, how well the tasks are being performed, if all family members ADLs and IADLs are being met, and if the division of labor is fair and reasonable - Expressive -- Family communication (influenced by culture, socioeconomic status, history, and emotions of family) - Developmental Assessment: Unique path of family - What stage of the path are they in? - The nurse should individualize the assessment of the family's current stage and its ability to accomplish the tasks that will allow the family to continue on its unique development **Genogram vs. Ecomap** - Genogram -- Diagram of family relationships between blood relatives that can span two or more generations - Life events such as marriages, divorces, births, and deaths are included in the diagram; it is used to identify relationships as well as possible patterns of disease - Ecomap -- Diagram used to identify the direction and intensity of family relationships between members and/or community institutions of importance to the family **Family Interview** - Five Leading Principles - Manners, therapeutic conversation, ecomaps / genograms, therapeutic questions, acknowledging family strengths **[Chapter 19: Environmental Health]** **Exposure Pathway** -- Describes how people are exposed to an environmental contaminant that originates from a specific source - Source of Contamination -- What is it? Where is it from? - 3 Types: Chemical (lead, mercury), biological (mold), radiologic - Sometimes type of contaminant is easy to identify (mercury-spill from a former thermometer factory) - Might be difficult to identify (vapor intrusion into a home from contaminated groundwater) - Does the toxin quickly break down in the environment? Or will it persist for many years? - This can indicate whether health effects can be expected long-term to exposed communities. - Contaminants may come from one source or multiple sources (oil spill that is washed away by rain into a neighboring lake) - Example: Flint water crisis the contaminant was lead from untreated pipes - Environmental Media and Transport Mechanisms -- How are people exposed? How does the contaminant move through the environment? - Environmental Media: Groundwater, surface water (lakes, ponds, rivers), air, surface soil, subsurface soil, sediment, plants and animals - Helps determine who is exposed and how they are exposed. - Transport mechanism is how the contaminant moves from the source to the point of exposure to people. - For example, if an old oil drum full of contaminant is buried, you want to know if it leaks will it get into the air? Or is it likely to get into the groundwater? - Example: In flint it was transported by water in untreated corroding pipes - Point of Exposure -- Where do people come into contact with toxins? - Exposure point could be a home, playground, lake, business, cloud of diesel fumes, an abandoned lot, a fish to be eaten or a park - Route of Exposure -- How does the contaminant enter the body? - Environmental contaminants enter the body primarily by ingestion, inhalation, or skin contact [ ] - Children may ingest soil when they're playing outside, putting things into their mouths, or not washing hands. - Example: In flint people got sick from ingestion of the water - Receptor Population -- What is the population of people that are likely to be exposed? Current exposure? Past exposure? Future exposure? - Where is the contaminant and who is likely to be exposed - Carefully and accurately consider the population at risk for exposure. - If the toxin is in the groundwater, then only people with drinking wells supplied by that groundwater are likely to be exposed. People with wells supplied by another source or people who use public water systems are not exposed. - *For a contaminant to pose a risk, there must be a completed exposure pathway* - Just because there is a complete exposure pathway does not indicate that you will become sick. - The exposure might not be great enough to cause illness. - Medicine does not know the effects of all toxins. - Depends on DOSE of toxin. **Environmental Justice** - Belief that no group of people should bear a disproportionate share of negative environmental health consequences (regardless of race, culture, income) and goal is to reduce disparities in environmental exposure - Often communities without political or economic power are at greatest risk - Interagency Workgroup on Environmental Justice - Farm workers: 50% of farm workers in US are Hispanic. Direct exposure to pesticides, often living nearby and exposing their children and families to these toxins. Illness from exposure may prevent them from working and increase poverty levels. - Tribal communities: At risk for disproportionate burden of exposure. Still practice traditional way of life Negatively affected by land and water contamination. If fishing grounds are deemed unsafe, they might be affected more than non-tribal communities. **Toxicology** - The study of the adverse effects of chemical, physical, or biologic agents on people, animals, and the environment **Bioavailability** - The amount of a contaminant that actually ends up in the systemic circulation **Health Effects of Lead, Asbestos, Carbon Monoxide** - Lead: - Source: Paint used prior to 1978, ceramics, pottery, pipes, soil - Exposure: Ingestion from dust in home or soil - Risk Groups: Children - Health Effects: Nervous system, developmental - Asbestos: - Source: Fiber used for insulation and as a fire retardant - Exposure: Inhalation - Risk Groups: Working in mining, milling, manufacturing or install/removal of asbestos before 1970s legislation. Secondhand exposure to family members - Health Effects: Lung cancer (mesothelioma) and lung disease (asbestosis) - Carbon Monoxide: - Source: Colorless odorless gas byproduct of combustion from home heating or cars in garage - Exposure: Inhalation - Risk Groups: Everyone is at risk. Persons with respiratory or cardiac disease, infants, or elderly most likely to get sick - Health Effects: Coma or death **Assessment (Taking Exposure History Using "I PREPARE")** - Assessing contaminants in the environment - People in communities often want to know their risk of getting sick from known or suspected exposure to contaminants - Risk assessment is not easy. Simple way to think of it is Hazard + Exposure=Risk - Think about exposure through EXPOSURE PATHWAY. - IF THE EXPOSURE IS NOT COMPLETE OR CAN BE DISRUPTED, THE CONTAMINANT SHOULD NOT AFFECT HEALTH - Proximity alone does not mean that you will get sick. - Taking an Exposure History (I PREPARE) - **I** (**Investigate Potential Exposures)** - Have you ever felt sick after coming in contact with a chemical, pesticide, or other substance? Do you have any symptoms that improve when you are away from your usual location (e.g., home or work)? - **P** (**Present Work)** - Are you exposed to any dust, fumes, solvents, radiation, loud noises, pesticides or other chemicals? Do you wear personal protective equipment (PPE)? Are work clothes worn home? Do coworkers have similar health problems? - **R** (**Residence)** - When was your home built? What type of heating? Are you doing any remodeling? Where does your drinking water come from? Any mold, mildew, or water damage issues in your home? - **E** (**Environmental Concerns)** - Are there environmental concerns in your neighborhood (air, water, soil)? What type 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 is the longest job held? Have you ever been in the military, worked on a farm, or done volunteer or seasonal work? - **A (Activities)** - What type of activities do you and your family engage in? 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)** - Agency for toxic substances and disease registry - Association of occupational & environmental clinics - Environmental Protection Agency - Safety Data sheets - OSHA - Local health department, Poison control center - **E** (**Educate)** - Are materials available to educate the patient? Can you minimize the risk of exposure? Have you discussed prevention strategies? What is the plan for follow-up? **Challenges to Environmental Epidemiology** - Limited availability of data on many contaminants and their effect on health - Limited understanding about how exposures to multiple contaminants may sicken people - Latency between exposure and illness can be very long. - Time‐consuming to perform - Resource intensive in terms of personnel and money - Inconclusive in determining if X contaminant caused Y illness **[Climate Change]** **Impact on Vulnerable Populations** - Pregnancy: - Increased climate temperatures associated with preterm birth - Evidence of increased humidity with pre-eclampsia and eclampsia - Air pollution and respiratory compromise - Children: - Kids spend a lot of time outdoors - Strong evidence of association between respiratory disease and environment - Kids less able to adapt to extreme heat - Susceptible to dehydration - Elderly: - Advanced age is one of the most significant risk factors for heat-related death in the U.S. - Pre-existing medical conditions (cardiac and respiratory disease) - More likely to live alone, have limited mobility, cognitive constraints, and reduced social contacts - Increased vulnerability - Poverty: - Vulnerable to changes in daily life - Disruptions to access to public services, displacement from homes, need to migrate with limited transportation options - Increased stress **Health Effects from Climate Change** - Direct Health Effects: Direct exposure to extreme weather events - Indirect Health Effects: (Effects of a disrupted climate system) changes in water availability, air quality, changes in agriculture and the economy - How Does Climate Change Impact Health? - Heat-Related Illnesses - Increase rates of heat stroke, exhaustion and death - Most vulnerable: infants, children, elderly, chronic comorbidities - Urban residents at risk because of heat trapping - Water Security and Drought - Floods and droughts can dramatically impact water availability - Insect-Borne Diseases - Viruses and bacteria are highly sensitive to temperature and rainfall - Increases potential for infection - e.g. Malaria reproduces at higher rate during hot temperatures and mosquitoes feed more frequently - Respiratory Diseases and Premature Death - Increase rates of acute respiratory symptoms - Asthma-related emergency room visits due to air pollution and allergic pollen - Most vulnerable: infants, children, elderly, chronic comorbidities - Mental Health - Directly: exposing people to trauma from natural disasters - Extreme heat related to aggressive behavior, high rates of criminal activity, and increased suicide rates - Natural disasters can lead to displacement, loss, and social disruption - Food Security - Climate change compromises agriculture, especially in areas that are unable to adapt - Predicted to worsen malnutrition in developing world - Extreme weather directly damages crops - Extreme Weather Events - Heat waves - Melting of snow and ice with rising sea levels - Changes in precipitation resulting in flooding and drought - More intense hurricanes and storms - Wildfires - Poor air quality