1. Environmental Health and Nursing

2. Nursing began with a focus on environmental health Florence Nightingale, born May 12, 1820, in Florence, Italy, died August 13, 1910, in London, England

3. “Despite the fact that a significant proportion of disease is attributable to environmental factors, environmental health is often viewed as an appendage of occupational health nursing rather than central to nursing’s vision of health.” Butterfield, 2002, p. 43

4. Objectives The objectives of this class are to: –identify links between health and the environment –explore the roles of nursing in environmental health –identify examples of environmental health issues –propose ways of incorporating environmental health principles into nursing practice, education, research and policy

5. Identify Links Between Health and the Environment

6. What is environmental health? Environmental health comprises “those aspects of human health, including quality of life, that are determined by physical, chemical, biological, social, and psychosocial factors in the environment. “It also refers to the theory and practice of assessing, correcting, controlling, and preventing those factors in the environment that can potentially affect adversely the health of present and future generations.” World Health Organization, 2007

7. Proximal environmental influences Myres & Betke, 2002. © Her Majesty the Queen in Right of Canada, represented by the Minister of Health (2005)

8. Global environmental influences © WHO, 2006. http://www.who.int/globalchange/en/index.html

9. Burden of environmental disease by WHO subregion, 2002 © WHO, 2006. http://www.who.int/quantifying_ehimpacts/publications/prevdisexecsume.pdf

10. Environmental health and social justice http://news.nationalgeographic.com/news/2007/09/photogalleries/pollution-pictures/photo2.html

11. Interactions between the human population and the physical environment (T. Myres, used with permission) Climate Urbanization Poverty Industrialization Environmental Hazards Pathways of Exposure Populations Health Outcomes Chemicals Microbiological Radiological Climate Noise Pesticides Air Water Soil Food Products Children First Nations Northern Seniors Workers All Canadians Cancer Diabetes Respiratory Cardiovascular Neuro- behavioural Injuries Sensitivities Research and Information

12. © Public Health Agency of Canada, 2005

13. © Her Majesty the Queen in Right of Canada, represented by the Minister of Health (2005)

14. Precautionary principle “In order to protect the environment, the precautionary approach shall be widely applied by States according to their capabilities. “Where there are threats of serious or irreversible damage, lack of full scientific certainty shall not be used as a reason for postponing cost- effective measures to prevent environmental degradation.” Rio Declaration, United Nations, 1992

15. Explore the Role of Nursing in Environmental Health

16. Why should nurses know about environmental health? 1. Environmental factors have an impact on health: –Smog and cardiovascular/respiratory diseases –Children’s exposure to lead –Prenatal exposures –Heat waves and elderly people –Women choosing to bottle feed because of contaminants in breast milk –Concerns over mercury in fish –Indoor air quality and asthma –Emergency planning –Commitment to social justice

17. Why should nurses know about environmental health? 2. Nurses are very, very good at teaching about health this skill supports work in protecting individuals, families and communities from environmental hazards 3.Nurses are the largest professional group working in health care working together we can be a powerful force for making improvements in the environment

18. The role of nurses in environmental health Assess and detect hazards when they exist Provide information to individuals and aggregates on the health effects of environmental toxins and more global hazards Report serious environmental threats to appropriate agencies Develop and implement school-based and workplace wellness programs Aid in the formulation of public policy and legislation involving the environment Help prevent excessive exposure to immediate toxins and larger, global hazards Help facilitate behaviour change in people International Council of Nurses

19. Importance of engaging all nurses Health of individuals, families, communities and populations affected by environment Every nurse should be able to: –Consider environmental factors that may be contributing to poor health –Understand environmental hazards and their impact on health –Perform an environmental assessment –Understand the role of individuals and communities in providing good stewardship of the environment –Make recommendations about how to reduce or prevent exposures to environmental hazards

20. Identify Examples of Environmental Health Issues

21. Selected environmental hazards (Thomlinson, 2003) Biological agents: bacteria, protozoa, viruses, fungi, algae, dust mites, pollen, moulds Chemical contaminants –Organic: fluorine, chlorine, bromine, iodine, nitrogen, sulfur, phosphorous, PCBs, DDT, dioxins, benzene, malathion, toluene –Inorganic: ozone, nitrogen oxides, sulphur dioxide, lead, mercury, cadmium, arsenic, etc. Radiation: microwaves, UV rays, noise Particulate matter: dust, smoke, asbestos, ETS

22. Risk Hazard Probability Adverse health effects Exposure Susceptibility Assessing risk Myres & Betke, 2002. © Her Majesty the Queen in Right of Canada, represented by the Minister of Health (2005)

23. How is the impact on health identified? Two types of studies assess risk: –Epidemiological studies look at patterns of health outcomes following identified exposures. –Toxicological studies look at the mechanisms of action of the exposure: i.e., the effects the exposure has on the body (animal or human).

24. Examples of environmental hazards and health outcomes Historical –Methyl mercury and Minamata disease (Japan)* –Lead in paint and reduced IQ in children (North America) –Dioxin contamination and chloracne (Seveso, Italy) –Lead in soil and neuro-developmental delay (Riverdale, Toronto) Current –Smog and cardiovascular disease* –Heat stroke and increased mortality among elderly people –Lead in paint and reduced IQ in children –Indoor air quality and asthma

25. Smog and cardiovascular disease There is strong evidence that exposure to air pollution leads to increased morbidity and mortality due to cardiovascular disease (CVD). (Pope & Dockery, 2006)

26. What is smog? The major components of smog are particulate matter (PM) and ozone. PM, which includes both inhalable particles (or PM 10 ) and fine particles (known as PM 2.5 ), is emitted directly into the atmosphere from such sources as: –Cars, trucks, factories, and wood burning, and –Can also be formed in the air from precursor gases such as nitrogen oxides (NO X ), volatile organic compounds (VOCs), sulphur dioxide (SO 2 ), and ammonia.

27. © Environment Canada http://www.ec.gc.ca/EnviroZine/english/issues/47/feature1_e.cfm

28. What is the evidence on PM and CVD? Epidemiological studies: –Mortality and morbidity due to CVD increased on days with high levels of PM (Pope & Dockery, 2006) –Response varies by PM concentration Hypothesized mechanisms of action: –Deposition of particles in the lung provoke a low-grade alveolar inflammation resulting in downstream exacerbations of CVD –Fine or ultra-fine particles “enter the blood and adversely affect the heart by initiating arrhythmias and sudden death in susceptible subjects” (Bai et al., 2007, p.18).

29. Estimated PM 10 concentrations in world cities © Development Economics Research Group & The Environment Department, The World Bank

30. Propose Ways of Incorporating Environmental Health Principles into Nursing Practice, Education, Research and Policy

31. Nursing Practice (Example: Smog) There are three ways that nurses can help protect the health of people with CVD (and other vulnerable populations) from smog: –Being aware of and teaching clients about the Air Quality Index (AQI) in their community –Making recommendations on reducing exposure to emissions –Promoting steps to reduce emissions Health Canada’s It’s Your Health series has useful fact sheets on environmental health issues.

32. Nursing Education Undergraduate curriculum –Include environmental health principles in a range of courses: maternal health, prevention of falls, community health, medical-surgical, etc. In-service education –Presentations by green team in hospital addressing environmental issues within health-care setting or community Ongoing professional development –CNA website, environmental health journals (Environmental Health Perspectives, Online Journal of Issues in Nursing)

33. Nursing Research Nurses as co-investigators –Working with researchers in a number of areas, particularly to support understanding of the perspective of populations on issues Nurses as investigators –Already studying how to modify the environment to prevent falls; could explore how perception of hazards affects behaviour Targeted funding –May need to “prime the pump” with funding targeted at environmental health issues

34. Policy Nurses are a credible source of health information (public opinion polls, 2007) Professional associations –work with members to identify key areas of action –include environmental health issues in advice to government –speak about environmental health issues where appropriate Community-based action –work with community members on an issue they have identified, such as concerns over water quality

35. Where to go for more information Environmental health and nursing –http://www.cna-aiic.ca/CNA/issues/environment/default_e.aspx Children’s health and the environment –http://www.who.int/ceh/en/ Health Canada: It’s Your Health: Environment –http://www.hc-sc.gc.ca/iyh-vsv/environ/index_e.html Health Canada: Climate Change and Health –http://www.hc-sc.gc.ca/ewh-semt/pubs/climat/index_e.html

36. Conclusions The environment has an impact on health. Nurses have a role in preventing exposures and reducing risks from environmental hazards. Nurses have the skills to be effective in addressing environmental health issues. What is needed is to increase our awareness and provide tools we can use, no matter what setting we work in.

38. © Canadian Nurses Association, 2008 Photos: Comstock; Corbis; Getty Images