NEHA March 2024 Journal of Environmental Health

Documenting Environmental Health Workforce E ectiveness As the environmental health workforce is integral to public health, it is important for the profession to consider how to document our impact. This documentation process will allow us to tell our story, which could lead to greater support and more interest in pursuing environmental health as a career. One way to do this is to take a comparative approach. The guidelines by Drew et al. (2000) sug- gest three di erent comparative methods that compare the present situation with: 1) a past situation, 2) other similar situations, or 3) a predetermined standard. There are challenges with all three approaches, including selecting the scale and scope of analysis and compiling the comparative data. First, the approach of comparing a pres- ent situation to a past situation could include reviewing current health data (e.g., on asthma) to past data in the context of environmental health activities, indicators, or funding. In this case, we can look for relationships between changes in environmental health funding in a specific location and changes in asthma cases. This time-series approach would require many years of analogous data and an understanding of the potential e ects of societal changes, such as a global pandemic. Goldstein et al. (2020) took this approach to examine changes in infant mortality over time using state expenditures on several social determinants of health. They found that changes in state- level infant mortality were related to changes in funding for several non-healthcare services. That is, those states that increased spending in public health, parks and recreation, and other environmental health services saw the greatest reductions in infant mortality. Another longitudinal study looked for a relationship between environmental health and diarrhea in Brazil (Souza et al., 2021). The authors used hospitalizations for diarrhea and malnutrition as the dependent variable and used the number of households having access to water and sanitation services as one of the independent variables. They determined that the percent change in hospitalizations for diar- rhea decreased relative to changes in access to clean water and sanitation over a 10-year period. The authors explain, however, that diarrhea is still too prevalent in children <5 years, so they call for more attention to envi- ronmental health services.

The second comparative approach of examining similar situations would include comparing health outcomes and environ- mental health indicators in one place to another place. Using asthma as an example, rates of asthma in one county or state could be compared with rates in another and related to levels of air pollution as an envi- ronmental health indicator. The benefit of this approach is that data are collected and reported within and among states by orga- nizations and governmental entities. The Robert Wood Johnson Foundation (RWJF) and America’s Health Rankings from the United Health Foundation (2022) are two sources of comparative data that are used often by all types of health researchers, including environmental health (Hendryx & Luo, 2020; Morrone, 2020). RWJF o ers data to the county level, while America’s Health Rankings provides state-level data for comparisons. The downside to this type of comparison is that it is only one point in time and thus only provides a cross-section for analysis. Comparing data to a predetermined stan- dard is a third approach and could include, for example, asthma rates as related to air quality regulations established by the U.S. Environ- mental Protection Agency (U.S. EPA). U.S. EPA sets maximum levels of specific outdoor air pollutants in the National Ambient Air Qual- ity Standards. With a few exceptions, states enforce these standards by continuously mon- itoring these pollutants at the county level. If a county does not meet the national standard, it is labeled a “nonattainment” area, and the state is required to submit a plan with correc- tive actions to U.S. EPA. This approach provides data to compare counties within states and is a way to highlight environmental inequities. Places that do not attain standards often comprise communities of color or other marginalized populations that are more vulnerable to the health impacts resulting from air pollution (Revesz, 2022). Using standards o ers researchers a way to compare population health based on relatively easily accessed regulatory data. It also allows for comparisons at the county level, which could be more informative because so much of public health is local. This type of compara- tive approach, however, is limited by data that are usually not current due to the lag time to compile and report the data.

the services are well targeted and man- aged properly, their e ects will produce the absence of an event. If there are no events to measure or discuss, how can a manager prove that the services are working properly? Due to the inherent challenges in provid- ing evidence of positive health outcomes from e ective environmental health, we need to take an approach that provides indicators of our impact that go beyond easily documented measures such as counting the number of inspections or responses to complaints. This approach is especially relevant for local health departments that might have only a few envi- ronmental health specialists who are respon- sible for hundreds of licensed facilities. Indeed, inspections are crucial elements of environmental health. When people can read inspection reports of their local restau- rants, they may be either alarmed or satis- fied, but chances are they do not equate this information with the e ectiveness of the environmental health workforce. What is lost in the inspection data, though, are the number of illnesses averted, or the “non- events” that WHO notes. Surveillance, if it happens at all, begins after the first illnesses are reported and, paradoxically, this timing could lead to public perceptions that envi- ronmental health professionals are ine ec- tive because people got sick. Identifying and recording the number of inspections, training sessions, engagements with community groups, and outbreak investigations does little to contribute to understanding the e ectiveness and com- plexity of the environmental health work- force. One crucial aspect of environmental health practice is gathering information that can be used in setting public health policy. In one study, “gathering information” was identified as the most important component of the daily work of environmental health professionals (Heidari et al., 2019). At least some of this information can be used in community health assessments (CHAs) and community health improvement plans (CHIPs), both of which are required ele- ments of public health department accredi- tation. Without environmental health pro- fessionals, public health departments would struggle to compile the materials needed for accreditation, public accountability, and minimizing the spread of disease.


March 2024 • Journal of Environmental Health

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