FIGURE 1
Correlation Coefficients for All Indicators Used
EPH
Health
Health Group
Variable
PreDeath PhysDis HiHlth Asthma Cancer
CVD COPD PHFund HlthPC NatPC RecPC SWPC SewerPC CDCPC21 FoodIns
Lead Severe AirPoll
DWater
PreDeath 1.000 PhysDis 0.804 1.000 HiHlth -0.867 -0.762
1.000 0.008 -0.166 -0.722 -0.688 0.154 0.364 0.093 0.110 0.136 0.305 0.417
Asthma 0.053
0.258 0.355 0.770 0.833
1.000 0.400 0.290 0.405 0.021 0.123
Cancer
0.315
1.000 0.617 0.562
CVD 0.805 COPD 0.774
1.000 0.920
1.000
EPH
PHFund -0.066 -0.170 HlthPC -0.229 -0.220
-0.335 -0.228 -0.198 -0.119 -0.215 -0.247
1.000 0.344 0.744 0.291 0.084 0.147 0.331
1.000 0.167 0.463 0.354 0.208 0.420
NatPC 0.029 RecPC 0.027
-0.002 -0.076
-0.165 -0.204 -0.154 -0.108 -0.101 -0.103 -0.006 -0.093
1.000 0.200 -0.076 -0.121 0.140
1.000 0.334 0.265 0.149 0.047 0.021 0.057
SWPC -0.143 -0.054 SewerPC -0.338 -0.314 CDCPC21 -0.311 -0.220
0.253 0.309 0.524
0.089
0.005
-0.055
1.000 0.463 0.280
-0.038 -0.226 -0.217
1.000 0.364
0.134 0.143 0.254
-0.181 -0.068
1.000
FoodIns 0.775
0.708
-0.734 -0.028
0.607
0.752
-0.163 -0.160 -0.088
-0.118 -0.382 -0.430
1.000 -0.391
Lead
-0.348 -0.330
0.329 0.123
0.399
-0.089 -0.060
0.024 0.313
0.107 0.196
-0.196 0.074
0.156 0.010
0.378 0.084
0.369
1.000
Severe -0.343 -0.279
-0.200 -0.595 -0.449 -0.475
-0.054 -0.149 -0.076
1.000 0.149 0.000
AirPoll DWater
0.187 0.359
0.313 0.263
-0.479 -0.113 -0.057
0.130 0.303
0.093 0.288
-0.410 -0.458 -0.250 -0.302 -0.045 -0.077 -0.485
0.283 0.262
-0.147 -0.014
1.000 0.045
-0.388
0.108
-0.014
0.202
-0.118
0.205
-0.040 -0.135 -0.133 -0.148
1.000
Note. Gray-shaded area depicts relationships between environmental health and health. For the health indicators: PreDeath = premature death; PhysDis = % physical distress; HiHlth = % high health status; Asthma = % asthma; Cancer = % cancer; CVD = % cardiovascular disease; COPD = % chronic obstructive pulmonary disease. For the environmental public health (EPH) indicators: PHFund = public health funding; HlthPC = per capita non-healthcare spending; NatPC = per capita national resources spending; RecPC = per capita recreation spending; SWPC = per capita solid waste spending; SewerPC = per capita sewer spending; CDCPC21 = per capita funding from the Centers for Disease Control and Prevention; FoodIns = % food insecure; Lead = % housing with high lead; Severe = % housing with severe problems; AirPoll = exposure to particulate matter; DWater = % with drinking water violations. See Table 1 for complete definitions of the indicators.
Study Objectives The purpose of this study is to explore rela- tionships between environmental health indicators and health outcomes. There are two objectives: 1. To identify potential indicators to dem- onstrate the impact of the environmental health workforce. 2. To assess the relationship between these indicators and health outcomes. Overall, this exploration will contrib- ute to the discussion about documenting the eectiveness and positive impact of the environmental health workforce. Part of this discussion must include improving public awareness and support for the profession. If it is possible to identify relationships between environmental health activities and health outcomes, then we might be able to develop messages that could contribute to a more robust and sustainable workforce. Methods To explore the relationship between envi- ronmental health and health outcomes, this study used an approach that compares simi- lar situations across states. The first challenge was to identify indicators of health and envi- ronmental health that are measured similarly
across the country. One important criterion was that these indicators should be relevant and easily obtainable. Most of the data come from the 2022 America’s Health Rankings (AHR) Annual Report or the U.S. Census Bureau. AHR is an annual report compiled by the United Health Foundation (2022) in col- laboration with the American Public Health Association. AHR is similar to the County Health Rankings from RWJF, but it ranks states rather than counties based on mul- tiple variables. The data are compiled from numerous sources, including the U.S. Census Bureau, governmental agencies such as the U.S. Department of Health and Human Ser- vices and U.S. EPA, and the Behavioral Risk Factor Surveillance System from the Centers for Disease Control and Prevention (CDC). After reviewing multiple studies and data- sets, indicators were identified as part of two major groups: 1) health and 2) environmental public health. Within these groups, there are 19 indicators within the 5 categories of general health, environmental-related health, finan- cial, environmental health, and environmental quality. Table 1 summarizes the groups, cat- egories, and indicators used in this study. The health group comprises two cat- egories: general health and environmental-
related health. General health indicators include years of potential life lost (i.e., premature death), percentage of adults who identify poor health status in the past month (i.e., physical distress), and self- reported health status (i.e., high health sta- tus). Environmental-related health indica- tors are linked to environmental conditions. For example, poor air quality exacerbates asthma, cardiovascular disease, and chronic obstructive pulmonary disease (COPD). Cancer is associated with multiple environ- mental exposures. There are three categories in the environ- mental public health group: financial, envi- ronmental health, and environmental quality. Financial indicators include per capita expen- ditures on recreation, solid waste manage- ment, sewage, non-healthcare-related activi- ties (includes environmental health), and natural resources. Environmental health and environmental quality subcategories include indicators such as drinking water violations, air pollution exposures, food insecurity, and lead levels in housing. Because this study was exploratory, an Excel spreadsheet was used for ease of analysis and to provide the ability to share data. Pearson correlation coecients were calculated.
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March 2024 • Journal of Environmental Health
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