Chapter 14Environmental HealthCopyright © 2015, 2011, 2007, .docx

Chapter 14
Environmental Health
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders,
an imprint of Elsevier Inc.
Environmental Health Is …
... all the physical, chemical, and biological factors external to a
person and all the related factors impacting behaviors.
… encompasses the assessment and control of those
environmental factors that can potentially affect health.
… targeted toward preventing disease and creating health-
supportive environments.
– WHO (2013)
2
Environmental Health
The purpose of environmental health is to ensure the conditions
of human health and provide healthy environments for people to
live, work, and play.
Accomplished through…
Risk assessment
Prevention
Intervention

3
Using a Critical Theory Approach
Uses “thinking upstream” framework.
Raises questions about oppressive situations.
Involves community members in the definition and solution of
problems.
Facilitates interventions that reduce health-damaging effects of
environments.
Asks critical questions about clients’ work and home
environments to help discern the contributions of specific
hazards to health.
4
Benefits of an Environmental Health History
Increased awareness of environmental/ occupational factors
Improved timelines and accuracy of diagnosis
Prevents disease and aggravation of conditions
Identifies potential work-related environmental hazards and/or
environmental hazards in and around clients’ homes
5
I PREPARE
Environmental Exposure History
I – Investigate potential exposures

P – Present work
R – Residence
E – Environmental concerns
P – Past work
A – Activities
R – Referrals and Resources
E – Educate
6
Figure 14-1
From U.S. Department of Health and Human Services: Healthy
People 2010, ed 2, Washington, DC, U.S. Government Printing
Office, 2000.
7
Areas of Environmental Health
Built environment
Work-related exposures
Outdoor air quality
Healthy homes
Water quality
Food, safety, and waste management
8

Built Environment
The connection between people, communities, and their
surrounding environments that affects health behaviors and
habits, interpersonal relationships, cultural values, and customs
9
Built Environment: Examples
Drunk driving
Second-hand smoke
Noise exposure
Urban crowding
Technological hazards
10
Work-Related Exposure
Poor working conditions that result in potential injury or illness
11

Work-Related Exposure: Examples
Asbestosis
Asthma
Lung cancer
Agricultural accidents
12
Outdoor Air Quality
The purity of the air and the presence of air pollution
13
Outdoor Air Quality: Examples
Gaseous pollutants
Greenhouse effect
Destruction of the ozone layer
Aerial spraying of herbicides and pesticides
Acid rain
14

Healthy Home
The availability, safety, structural strength, cleanliness, and
location of shelter, and indoor air quality
15
Healthy Home: Examples
Homelessness
Rodent and insect infestation
Poisoning from lead-based paint
Sick building syndrome
Unsafe neighborhoods
16
Water Quality
The availability, volume, mineral content levels, toxic chemical
pollution, and pathogenic microorganism levels
The balance between water contaminants and existing
capabilities to purify water for human use and plant and wildlife
sustenance

17
Water Quality: Examples
Contamination of drinking supply by human waste
Oil spills in the world’s waterways
Pesticide or herbicide infiltration of ground water
Aquifer contamination by industrial pollutants
Heavy metal poisoning of fish
18
Food Safety
Availability, accessibility, and relative costs of healthy food
free from contamination of harmful herbicides, pesticides, and
bacteria
19
Food Safety: Examples
Malnutrition

Bacterial food poisoning
Food adulteration
Disrupted food chains by ecosystem destruction
Carcinogenic chemical food additives
20
http://www.foodsafety.gov/
Figure 14-5
FDA food safety campaign:
http://www.fightbac.org/safe-food-handling
Waste Management
The handling of waste materials resulting from industry,
municipal processes, and human consumption as well as efforts
to minimize waste production
21
Waste Management: Examples
Use of nonbiodegradable plastics
Poorly designed solid waste dumps
Inadequate sewage systems
Transport and storage of hazardous waste
Illegal industrial dumping

22
Waste Management: Examples (Cont.)
Nuclear facility emissions
Radioactive hazardous wastes
Radon gas seepage in homes and schools
Nuclear testing
Excessive exposure to x-rays
23
Effects of Environmental Hazards
24
Figure 14-6 From Environmental Protection Agency: Air
Pollution and Health Risk.
http://www.epa.gov/ttnatw01/3_90_022.html. Retrieved March
27, 2013.
Emerging Issues in Environmental Health
Environmental public health infrastructure
Natural disasters
Global climate change

Ozone depletion
Fossil fuel burning
Marine dumping
Active land mine abandonment in war-torn areas
Destruction of tropical rain forests
25
Critical Community Health Nursing Practice
Approach environmental health at the population level
Take a stand; advocate for change
Ask critical questions
Facilitate community involvement
Form coalitions
Using collective strategies
26
Chapter 13
Cultural Diversity and Community Health Nursing
1

Cultural Competence
Cultural competence is respecting and understanding the values
and beliefs of a certain cultural group so that one can function
effectively in caring for members of that cultural group.
Culturally competent community health nursing requires that
the nurse understand…
Lifestyle
Value system
Health and illness behaviors of diverse individuals, families,
groups, and communities
2
Standards of Practice for Culturally Competent Nursing Care
Social Justice
Critical Reflection
Knowledge of Cultures
Culturally Competent Practice
Cultural Competence in Health Care Systems and Organizations
Patient Advocacy and Empowerment
Multicultural Workforce
Education and Training in Culturally Competent Care
Cross-Cultural Communication
Cross-Cultural Leadership
Policy Development
Evidence-Based Practice and Research
From: Expert Panel on Global
Nursing and Health (2010)
3

Population Trends
In 1970
Minority groups were 16% of population
By 2010
Minority groups increased to 36% of population
By 2025
More than half of all children will be minorities
By 2050
More than 54% of total population will be minorities
First time in U.S. history that minorities will make up a
majority of the population
4
4
Population Trends (Cont.)
By 2060, projected demographic trends:
White 44%
Hispanic 30%
African American 15%
Asian 9%
American Indians & Alaska Natives 2%
5
5

Immigration to the United States
Since 1991, more than 13 million legal immigrants
In 2010, almost 40 million foreign-born individuals in the
United States (12.9% of population) from:
Latin America 53.1%
Asia 28.2%
Europe 12.1%
Other regions 9%
6
Diversity Among Nurses
Minorities are generally underrepresented by nursing workforce
(HRSA, 2009):
White/non-Hispanic 81.8%
African American 4.2%
Hispanic 1.7%
Asian and Pacific Islander 3.1%
Native American and Alaska Native 0.3%
Minority groups tend to be geographically distributed in the
United States.
7
7
Cultural Perspectives and Healthy People 2020

Developed a set of national health targets…eliminating racial
and ethnic disparities in health
Embraced and focused on ways to close the gaps in health
outcomes
Focused on disparities among racial and ethnic minorities,
women, youth, older adults, people of low income and
education, and people with disabilities
8
8
Health Disparities
AHCRQ (2005) reveals that:
Cancer mortality rates are 35% higher in African Americans
than in whites.
African Americans with diabetes are seven times more likely to
have amputations and develop renal failure than are whites with
diabetes.
30% of Hispanics and 20% of African Americans lack a usual
source of health care (compared with less than 16% of whites).
9
9
Health Disparities (Cont.)
AHCRQ (2005) reveals that:

Hispanic children are nearly three times as likely as non-
Hispanic white children to have no usual source of health care.
African Americans (16%) and Hispanic Americans (13%) are
more likely to rely on hospitals or clinics for health care than
are whites (8%).
10
Addressing Racial and Ethnic Disparities in Health Care
Disparities can be reduced or eliminated when adults have:
Health insurance and
A medical home
– Commonwealth Fund, 2007
11
11
Transcultural Nursing
“…a formal area of study and practice focused on a comparative
analysis of different cultures and subcultures in the world with
respect to cultural care, health and illness beliefs, values, and
practices with the goal of using this knowledge to provide
culture-specific and culture-universal nursing care to people.”
– Leininger (1978)
12

12
Transcultural Nursing Terminology
Culture specific refers to the “particularistic values, beliefs, and
patterning of behavior that tend to be special, ‘local,’ or unique
to a designated culture and which do not tend to be shared with
members of other cultures”
Culture universal refers to the “commonalties of values, norms
of behavior, and life patterns that are similarly held among
cultures about human behavior and lifestyles and form the bases
for formulating theories for developing cross-cultural laws of
human behavior”
13
13
Transcultural Nursing Terminology (Cont.)
Ethnocentrism is a person’s tendency to view his or her own
way of life as the most desirable, acceptable, or best, and to act
in a superior manner toward another culture.
Cultural imposition is a person’s tendency to impose his or her
own beliefs, values, and patterns of behavior on individuals
from another culture.
14

14
Leininger’s Theory of Culture Care Diversity and Universality
Describes, explains, and projects nursing similarities and
differences focused primarily on human care and caring in
human cultures.
Uses world view, social structure, language, ethnohistory,
environmental context, and the generic or folk and professional
systems to provide a comprehensive and holistic view of
influences in cultural care and well-being.
15
15
Leininger’s Sunrise
Model depicting the
theory of cultural
care diversity and
universality
16
Figure 13-1
From Leininger MM: Culture, care, diversity, and universality:
a theory of nursing, New York, 1991, National League for
Nursing Press.

16
Overview of Culture
Culture refers to the complex whole, including knowledge,
beliefs, art, morals, law, customs, and any other capabilities and
habits acquired by virtue of the fact that one is a member of a
particular society (Tylor, 1871).
Culture represents a person’s way of perceiving, evaluating, and
behaving within his or her world, and it provides the blueprint
for determining his or her values, beliefs, and practices.
17
17
Overview of Culture (Cont.)
Four basic characteristics of culture—it is:
Learned from birth through the processes of language
acquisition and socialization
Shared by members of the same cultural group
Adapted to specific conditions related to environmental and
technical factors and to the availability of natural resources
Dynamic
– Sir Edward Tylor, 1871
18
Subculture

A fairly large aggregate of people who share characteristics that
are not common to all members of the culture
Enables them to be a distinguishable subgroup
May be based on ethnicity, religions, occupation, health-related
characteristics, age, gender, sexual preferences, or geographic
location
19
Culture and Formation of Values
Common human problems related to values and norms:
What is the character of innate human nature (human nature
orientation)?
What is the relationship of the human to nature (person-nature
orientation)?
What is the temporal focus of human life (time orientation)?
What is the mode of human activity (activity orientation)?
What is the mode of human relationships (social orientation)?
20
Human-Nature Orientation
Innate human nature may be good, evil, or a combination of
good and evil.
The dominant U.S. cultural group chooses to believe the best
about a person until that person proves otherwise.
– Kohls (1984)
21

Person-Nature Orientation
Destiny, in which people are subjugated to nature in a fatalistic,
inevitable manner.
Harmony, in which people and nature exist together as a single
entity.
Mastery, in which people are intended to overcome natural
forces and put them to use for the benefit of humankind.
22
Time Orientation
The focus may be on the past, with traditions and ancestors
playing an important role in the client’s life.
The focus may be on the present, with little attention paid to the
past or the future.
The focus may be on the future, with progress and change
highly valued.
23
Activity Orientation
Being, in which a spontaneous expression of impulses and

desires is largely nondevelopmental in nature.
Growing, in which the person is self-contained and has inner
control, including the ability to self-actualize.
Doing, in which the person actively strives to achieve and
accomplish something that is regarded highly.
24
Social Orientation
Lineal relationships: Exist by virtue of heredity and kinship
ties. Follow an ordered succession and have continuity through
time.
Collateral relationships: Focus primarily on group goals—and
family orientation is important.
Individual relationships: Personal autonomy and independence
dominate; group goals become secondary.
25
Culture and the Family
Cross-cultural differences may exist in:
Structural differences
Functional diversity
Socialization context
Sex roles and parenting values

26
Culture and Socioeconomic Factors
Socioeconomic status (SES) is a composite of the economic
status of a family or unrelated individuals based on:
Income
Wealth
Occupation
Educational attainment
Power
27
Culture and Socioeconomic Factors (Cont.)
Poverty guidelines
Determined by comparing pretax cash income with the poverty
threshold adjusted for family size and composition issued
annually by USDHHS.
The U.S. Census Bureau (2012) reported that the poverty rate in
2011 was 15%
African American population—27.6%
Asian population—12.3%
Hispanic population—25.3%
Children under 6 years—24.5%

28
Distribution of resources
Upper, middle, and lower classes
Total family income, occupation, and educational level
Age, sex, material possessions, health status, family name,
location of residence, family composition, amount of land
owned, religion, race, and ethnicity
A disproportionate number of individuals from the racially and
ethnically diverse subgroups are members of the lower
socioeconomic class
Outcome of social stratification is social inequality
29
Education
Perhaps the single most important factor in SES.
Child’s educational development affected more by differences
in levels of formal schooling than by cultural differences or
economic indices.
30

Culture and Nutrition
Culturally competent nutrition assessment:
Cultural definition of food
Frequency and number of meals eaten away from home
Form and content of ceremonial meals
Amount and types of food eaten
Regularity of food consumption
Social contacts during meals
Beware of cultural stereotyping.
Cultural food preferences are often interrelated with religious
dietary beliefs and practices.
31
Culture and Religion
Culturally competent nursing care and religious factors:
Gain a general understanding of religious calendars.
Know the customary days of religious worship.
Learn about special days of observance or celebration.
Ask clients what religious practices they follow.
Religious beliefs may influence a client’s belief about the cause
of illness, perception of its severity, choice of healer, and
source of consolation.
Assess spiritual needs of clients.
Know the difference between religion and spirituality.
Remember that various religions have shared beliefs.
32

Culture and Aging
Different cultures view older adults in very
different ways.
Tasks of older adults
To achieve a sense of integrity in accepting responsibility for
their own lives
To have a sense of accomplishment
Older adults develop their own means of coping with illness
through self-care, assistance from others, and social support
groups.
33
Cross-Cultural (Intercultural) Communication …
… between a nurse and client attempts to understand the other’s
point of view from a cultural perspective.
Nurse-client relationship
Space, distance, and intimacy
Overcoming communication barriers
Nonverbal communication
Language
Touch
Gender
34

Health-Related Beliefs and Practices
Understand personal culturally based values, beliefs, attitudes,
and practices.
Include the client’s beliefs about the cause of illness:
Biomedical perspective
Naturalistic perspective
Magicoreligious perspective
Understand the role and value of folk or religious healers.
35
Health-Related Beliefs and Practices (Cont.)
Cultural variations exist in how symptoms and disease
conditions are perceived, diagnosed, labeled, and treated.
Expression of pain is culturally determined.
Some conditions are culturally defined—a culture-bound
syndrome.
36
Management of Health Problems:
A Cultural Perspective
First effort at treatment is often self-care.

Mobilizes client’s social support network
Provides a caring environment
Cultural negotiation is used when conceptual differences exist
between client and nurse.
Same words but different meanings
Same phenomenon; different notions of causation
Different memories or emotions associated with the term and its
use
37
Cornerstones of Public Health Nursing
Focus on health of entire population
Reflect communities’ priorities and needs
Establish caring relationships
Remain grounded in social justice
Provide care for the whole person
Promote health based on epidemiological evidence (evidence-
based practice)
Collaborate with community resources
– Keller, Strohschein, & Schaffer, 2011
38
Management of Health Problems in Culturally Diverse
Populations
Providing health information and education
Delivering and financing health services
Developing health professionals from minority groups
Enhancing cooperative efforts with the nonfederal sector

Promoting a research agenda on minority health issues
39
Providing Health Information and Education
Developing programs to increase public awareness about health
problems.
Plan health information campaigns:
Be sensitive to cultural factors.
Involve community leaders.
Acknowledge existing cultural beliefs and practices.
Involve families, churches, employers, and community
organizations as support systems.
Use lay volunteers to organize community support networks.
Client education should be interpersonal; carefully use credible
printed materials and audiovisuals.
40
Role of the Community Health Nurse
Conduct a “culturological” assessment.
Conduct a cultural self-assessment.
Seek knowledge about local cultures.
Recognize political issues of culturally diverse groups.
Provide culturally competent care.
Recognize culturally based health problems.

41
Culturological Assessment
Brief history of ethnic and racial origins of the cultural group
with which the client identifies
Values orientation
Cultural sanctions and restrictions
Communication
Health-related beliefs and practices
Nutrition
42
Culturological Assessment (Cont.)
Socioeconomic considerations
Organizations providing cultural support
Educational background
Religious affiliation
Cultural aspects of disease incidence
Biocultural variations
Developmental considerations
43

Resources for Minority Health
U.S. Department of Health and Human Services and Public
Health Service
Office of Minority Health
Disadvantaged Minority Health Improvement Act of 1990
Indian Health Service
Indian Self-Determination Act of 1975
National Institutes of Health
National Center on Minority Health and Health Disparities
(NCMHD)
44
Federally Sponsored Initiatives to Improve Health of Minority
Groups
HRSA Health Disparity Collaboratives (HDC)
Racial and Ethnic Approaches to Community Health (REACH
2010)
National Breast and Cervical Cancer Early Detection Program
(NBCCEDP)
Ryan White Comprehensive AIDS Resources Emergency
(CARE) Act B
National Center on Minority Health and Health Disparities
(NCMHD)
45

Chapter 4
Health Promotion and Risk Reduction
.
Health Promotion Is…
…any combination of health education and related
organizational, economic, and environmental supports for
behavior of individuals, groups, or communities conducive to
health (Green & Kreuter, 1991)
…that which is motivated by the desire to increase well-being
and to reach the best possible health potential (Parse, 1990)
2
Health Protection Is …(Cont.)
… those behaviors in which one engages with the specific intent
to prevent disease, detect disease in the early stages, or
maximize health within the constraints of disease (Parse, 1990)
… an important step in maintaining health
3

Defining Health
The way health is defined has shifted from a focus on the
curative model, to a focus on multidimensional aspects such as
the social, cultural, and environmental facets of life and health
(Benson, 1996)
Health is viewed not only as an important goal, but as a
resource for living (WHO, 1986)
4
Healthy People 2020 …
… is the health promotion initiative for the nation.
… challenges individuals, communities, and professionals … to
take specific steps to ensure that good health, as well as long
life, are enjoyed by all.
– U.S. Department of Health and
Human Services, 2012
5
Healthy People 2020 …
(Cont.)
Broad goals

Attain high-quality, longer lives free of preventable disease,
disability, injury, and premature death.
Achieve high equity, eliminate disparities, and improve the
health of all groups.
Create social and physical environments that promote good
health for all.
Promote quality of life, healthy development, and healthy
behaviors across all life stages.
6
Determinants of Health
Biology
Behaviors
Social environment
Physical environment
Policies and interventions
Access to high-quality health care
7
Figure 4-1
From U.S. Department of Health and Human Services.

8
Theories in Health Promotion
Pender’s Health Promotion Model (HPM)
Health Belief Model (HBM)
Transtheoretical Model (TTM)
Theory of Reasoned Action (TRA)
9
Risk and Health
Risk is “the probability that a specific event will occur in a
given time frame” (Oleckno, 2002).
A risk factor is an exposure that is associated with a disease
(Friis & Sellers, 2004).
Risk Assessment is a systematic way of distinguishing the risks
posed by potentially harmful exposures.
10
Steps in Risk Assessment
Hazard identification
Risk description

Exposure assessment
Risk estimation
11
Risk Assessment
Modifiable risks
Individual has control
Examples: smoking, lifestyle, eating habits, activities
Nonmodifiable risks
Individual has little or no control
Examples: genetics, gender, age, environmental exposure
12
Risk Reduction …
… is a proactive process
… enables individuals to react to actual or potential threats to

their health
Risk communication …
… is the process of informing the public regarding threats
… is affected by perceptions, process, and actions
13
Tobacco and Health Risk
Leading cause of preventable death
Most common in less educated populations and those living
below poverty level
Most common form of chemical dependency
Tobacco in all forms is harmful.
14
Health Promotion Activities
15
Look for teachable moments
Assess client’s tobacco use
Explore willingness to quit
Refer to cessation programs
Encourage attempts to quit

Alcohol Consumption and Health
Third leading lifestyle-related cause of death for the nation
Short-term use causes acute risks
Long-term effects have major impact on health and social issues
Influenced by legal drinking age
# 1 used and abused drug among U.S. youth
16
Health Promotion Activities (Cont.)
Prevent underage drinking
Assist with enforcement of legal drinking age
Identify individuals and groups at risk of abuse and dependence
Educate adults and youth on dangers of alcohol
Requires a community-wide effort to address the problem on
several fronts
17
Diet and Health
Diet—one of most modifiable risk factors
Imbalance of caloric intake and physical activity

Complex interplay among metabolism, genetics, behavior,
environment, culture, and socioeconomic status
Geographic areas, age, ethnicity all influence weight
18
Special populations have different nutritional needs
For individualized plans, see http://myplate.gov/
Educate clients about:
Balancing caloric intake and physical activity
Servings vs. portion control
Eating away from home affects “portion distortion”
Using social media and mobile applications to help
19
Physical Activity and Health
20
Physical activity serves both health promotion and disease
prevention purposes
Leisure activities are influenced by level of education, gender,
age, economic level, geography
One’s environment plays a significant role in activity level

21
Support and develop “walkable” neighborhoods and cities
Determine recommended exercise levels for individuals
Visit http://www.cdc.gov/physicalactivity/data/facts.html
Sleep and Health
22
Sleep is an essential component of chronic disease prevention
and health promotion
Requirements change with age and life circumstances
Regulated by waking time and circadian rhythms
Hormones during sleep affect memory, blood pressure, and
kidney function.
23

Sleep assessment is important
Identify disorders that may affect daily activities
Keep sleep log
Practice sleep hygiene
Establish environment that promotes sleep
Avoid food and activities that interfere with sleep

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