Environmental Health
“Environmental health comprises those aspects of human health, including quality of life, that are determined by physical, chemical, biological, and social and psychological problems 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.”
From Protection of the Human Environment, published by the World Health Organization (2006, para. 1)
Objectives
After reading this chapter, the student should be able to do the following:
1. Explain the relationship between the environment and human health and disease.
2. Understand the key disciplines that inform nurses’ work in environmental health.
3. Apply the nursing process to the practice of environmental health.
Key Terms
agent, p. 222
bioaccumulated, p. 236
biomonitoring, p. 221
climate change, p. 223
compliance, p. 234
consumer confidence report, p. 227
environment, p. 222
environmental justice, p. 236
environmental standards, p. 234
epidemiological triangle, p. 222
epidemiology, p. 222
epigenetics, p. 221
geographic information systems (GISs), p. 222
global warming, p. 223
host, p. 222
indoor air quality, p. 226
Industrial Hygiene Hierarchy of Controls, p. 232
methylmercury, p. 236
monitoring, p. 234
non–point sources, p. 225
permit, p. 234
permitting, p. 234
persistent bioaccumulative toxins (PBTs), p. 236
persistent organic pollutants (POPs), p. 236
point sources, p. 225
precautionary principle, p. 230
right to know, p. 227
risk assessment, p. 228
risk communication, p. 233
risk management, p. 232
route of exposure, p. 233
toxicants, p. 229
toxicology, p. 221
—See glossary for definitions
Barbara Sattler, RN, DrPH, FAAN
Dr. Barbara Sattler is a Professor and the Director of the Environmental Health Education Center at the University of Maryland School of Nursing, which hosts a graduate program for nurses in environmental health and a post-master’s certificate in environmental health. She is the principal investigator and director of several grant-funded, environmental health–related projects. Over the years, Dr. Sattler’s work has included lead poisoning prevention; healthy homes and schools; environmentally healthy and sustainable hospitals, safe drinking water; and community-based activities in areas of contaminated land. She has served on a number of federal advisory committees to the Environmental Protection Agency; on Institute of Medicine Committees, and on several state-level commissions, including the Governor’s Commission on Environmental Justice. She is a founding member of the Alliance of Nurses for Healthy Environments. Her master’s and doctorate degrees are in public health from Johns Hopkins University School of Public Health. She is a co-author of Environmental Health and Nursing Practice (Sattler and Lipscomb, 2002).
ADDITIONAL RESOURCES
Website
http://evolve.elsevier.com/Stanhope
• WebLinks—Of special note see the link for these sites:
– e-Commons.org Alliance of Nurses for Healthy Environments
– National Library of Medicine online toxicology tutorial
• Quiz
• Glossary
Appendixes
• Appendix F.3: Comprehensive Occupational and Environmental Health History
• Appendix H: Focus on Quality and Safety Education for Nurses
Our homes, schools, workplaces, and communities are the environments in which most of us can be found at any given time. Potential risks to health exist in each of these environments. As nurses, who are one of the most trusted conveyors of information to the public, it is our responsibility to understand as much as possible about these risks—how to assess them, how to eliminate/reduce them, how to communicate and educate about them, and how to advocate for policies that support healthy environments. In 2010, the American Nurses Association (ANA) established an environmental health standard, within the Scope and Standards of Professional Practice that define the profession of nursing (Box 10-1). This means that all nurses are now expected to have knowledge of and skills associated with environmental health.
There are many ways in which environmental health threats can occur. If you have children and regularly use insecticides in your home, you increase their risk of contracting leukemia. The more you use insecticides, the greater the risk of leukemia (Infante-Rivard et al, 1999; Turner et al, 2010). The greatest risk to the child occurs when the mother is exposed to insecticides indoors during pregnancy (Brown, 2004). Childhood leukemia is also associated with prenatal exposures by parents with occupational exposures to pesticides (Wigle et al, 2009). The use of professional pest control services at any time from 1 year before birth to 3 years after was associated with a significantly increased risk of childhood leukemia (Ma et al, 2002). Many playing fields where children compete in sports are regularly sprayed with pesticides.
In May 2010, the President’s Cancer Panel proclaimed that the contribution that environmental carcinogens have made to the burden of cancer in the United States has been grossly underestimated. In addition to the main focus on chemical carcinogens, the panel noted the importance of radiation sources—ionizing and non-ionizing. In a letter to the President, they wrote: “The Panel urges you most strongly to use the power of your office to remove the carcinogens and other toxins from our food, water, and air that needlessly increase our health care costs, cripple our Nation’s productivity and devastate American lives” (President’s Cancer Panel, 2010). With this call came a range of recommendations for reducing the risk of cancer, both through individual choices and through national policy (Box 10-2). The recommendations for individuals are found in Resource 10.A on the Evolve resources website. There is also a document online at http://deainfo.nci.nih.gov/advisory/pcp/pcp08-09rpt/PCPReport 08-09 508.pdf that has an excellent section on recommendations for policy and research.
An estimated 52 million homes in the United States contain some lead-based paint. Exposure to lead can cause premature births, learning disabilities in children, hypertension in adults, and many other health problems. Lead poisoning is a completely preventable disease (Figure 10-1). Of the top 20 environmental pollutants that were reported to the Environmental Protection Agency (EPA), nearly three fourths were known or suspected neurotoxics. In the United States alone, this accounted for more than a billion pounds of neurotoxicants being released into the air, water, and land (Goldman, 1998). Thirty million Americans drink water that exceeds one or more of the EPA’s safe drinking water standards, and 50% of Americans live in an area that exceeds current national ambient air quality standards. When these standards are exceeded, there is an increased risk to the public for a wide range of health effects.
Although food labeling includes nutritional information, there is no requirement to label whether pesticides are used in the food production; whether non-therapeutic antibiotics were given to the livestock, poultry, or farmed fish; the presence of genetically engineered foods in a product; or whether recombinant bovine growth hormone was given to the dairy cows. Nurses have declared that the “right to know” about potentially hazardous exposures is one of the basic principles of environmental health (see Box 10-1). Nurses have a range of potential public health responsibilities in protecting the public from exposures and environmental health risks.
Nurses’ environmental assessments begin with a set of questions: What exposures can you identify in your own home? Do you use pesticides? Does your home have lead-based paint? Is it chipping or peeling? Are any of your appliances or heat sources producing unhealthy levels of carbon monoxide? Have you checked your home for radon, the second largest cause of lung cancer in the United States? How about your workplace? Do you use latex gloves? Do you use medical equipment that contains mercury, such as mercury thermometers or sphygmomanometers, which can contribute to the environmental mercury load that has contaminated fish in lakes and streams in more than 40 states?
Chemical, biological, and radiological exposures may contribute to health risks via the air we breathe (indoors and out), the water we drink, the food we eat, and/or the products we use. The mass media is alerting the public to health risks associated with foodborne illnesses, contaminated drinking water, indoor and outdoor air triggers to asthma (including mold),
LINKING CONTENT TO PRACTICE
Key documents that guide practice in both nursing and public health direct practitioners to be knowledgeable about and apply in their work principles related to environmental health. Specifically, the core competencies of the Council on Linkages has, with the domain of public health science skills, a competency that says practitioners will apply “the basic public health sciences (including, but not limited to, environmental health sciences, health services administration, and social and behavioral health sciences) to public health policies and programs.” The Quad Council of Nursing further applies this competency specifically to public health nursing practice by adding that these skills are applied to public health nursing practice, policies, and programs. The most explicit set of principles are those developed by the ANA in their principles of environmental health for nursing practice.
The ANA (2007) lists 10 principles of environmental health. Although all 10 are essential, three are highlighted here. Nurses should know about environmental health concepts, participate in assessing the quality of the environment in which they practice, and live and use the Precautionary Principle (which is discussed later in the chapter) to guide their work. Another principle points out that healthy environments are sustained through multidisciplinary collaboration, which is a key concept discussed throughout the chapter.
From American Nurses Association: ANA’s principles of environmental health in nursing practice with implementation strategies, Silver Spring, MD, 2007, author; Council on Linkages Between Academic and Public Health Practice: Core competencies for public health professionals: Washington, DC, 2010, Public Health Foundation/Health Resources and Services Administration; Quad Council of Public Health Nursing Organizations: Competencies for Public Health Nursing Practice, Washington, DC, 2003, ASTDN, revised 2009. Accessed December 15, 2010.
and environmental threats from potential terrorists. If the general public knows this, then nurses must be a step ahead and be prepared to answer our clients’ and communities’ questions. Therefore, nurses must understand how to assess the health risks posed by the environment and develop educational and other preventive interventions to help individual clients and their families as well as communities understand and, when possible, decrease their risks. The Institute of Medicine (IOM) of the National Academy of Science recommends that all nurses have a basic understanding of environmental health principles and that these principles are integrated into all aspects of our practice, education, advocacy, policies, and research. In this chapter, we will explore the basic competencies recommended by the IOM. Box 10-3 presents the competencies recommended by the IOM report, Nursing, Health and Environment (Pope, Snyder, and Mood, 1995).
HEALTHY PEOPLE 2020 OBJECTIVES FOR ENVIRONMENTAL HEALTH
Environmental health is one of the priority areas of the Healthy People 2020 objectives. The federal government has long recognized the importance of the relationship between environmental risks and the underlying factors contributing to diseases. Selected examples of the Healthy People 2020 environmental health objectives are outlined in the Healthy People 2020 box.
HEALTHY PEOPLE 2020
Examples of Objectives Related to Environmental Health
• EH-8.1: Eliminate elevated blood level levels in children.
• EH-9: Minimize the risks to human health and the environment posed by hazardous sites.
• EH-10: Reduce pesticide exposures that result in visits to the health care facility.
• EH-11: Reduce the amount of toxic pollutants released into the environment.
• EH-13: Reduce indoor allergen levels.
• EH-18: Decrease the number of U.S. homes that are found to have lead-based paint or related hazards.
From U.S. Department of Health and Human Services: Healthy People 2020. Available at http://www.healthypeople.gov/2020topicsobjectives2020/default.aspx. Accessed January 1, 2011.
Historical Context
Historically, nurses and physicians have been taught little about the environment and environmental threats to health. In 1995 the IOM produced the report Nursing, Health and Environment (Pope, Snyder, and Mood, 1995), which recognized the environment as a significant determinant of health and acknowledged that this recognition is, in fact, deeply rooted in nursing’s heritage. Pictures of and quotes from Florence Nightingale are used throughout the report, not only because she is a recognized symbol of nursing (i.e., the lady with the lamp), but also because of the central focus of environment in her practice and writings.
Nightingale is well-known for her work in the Crimea and is often called “the mother of biostatistics” for her skilled use of data, including her observations and compilation of information to compel action on conditions affecting population-based health. Early in the twentieth century, Lillian Wald, who coined the name “public health nurses,” spent her life improving the environment of the Henry Street neighborhood and working her broad network of influential contacts to make changes in the physical environment and social conditions that had direct health impacts. As modern day nurses are rediscovering environmental health, they are reintegrating many of the observations and skills that were practiced by early nurse pioneers.
There are many communities like the ones that Lillian Wald served. Poverty is highly associated with health disparities. In addition, poverty is associated with living in sub-standard housing, living closer to hazardous waste sites, working in more hazardous jobs, having poorer nutrition, and having less access to quality health care (particularly preventative services). The term environmental justice issue refers to the disproportionate environmental exposures that poor people and people of color experience. Poor people and people of color often live in sub-standard housing and experience the risks from chipping and peeling paint, pests and use of pesticides, inadequate heating sources with attendant carbon monoxide exposure, and locations that are near industry, hazardous waste sites, and highways. These populations also often have poor access to fresh produce, work in the most hazardous jobs, and lack access to quality health care. These combined circumstances contribute to health disparities.
It is important to note how we began to understand the relationship between environmental chemical exposures and their potential for harm. There are several ways in which we have historically made such discoveries:
However, the most common way in which the relationships between chemical exposures and health risks are identified is when toxicologists study the effects of chemicals on animals and [we] then estimate what the effects might be on humans. This estimation process is called extrapolation. More than 100,000 man-made (synthetic) chemical compounds have been developed and introduced to our environment since World War II, and we are most often reliant on the data that are created in animal studies to warn us about their potential toxicity to humans. For many of these chemicals, no toxicity data are available (Sattler and Lipscomb, 2002). Surprisingly, there is no current requirement for original toxicological research to be completed when a product or process is being brought to market.
We live in a radically different environment compared to a century ago. In addition to man-made pollutants contaminating our air, water, and food, many of the same pollutants are now also found in our bodies (including breast milk). In 2001, the Centers for Disease Control and Prevention began biomonitoring—the testing of human fluids and tissues for the presence of potentially toxic chemicals, as part of its National Health and Nutrition Exam Study. For instance, most Americans carry pesticides, solvents, heavy metals and other potentially toxic chemicals in their bodies. In 2005 an Environmental Working Group tested the umbilical cord blood of newborn babies and found that they also contained a wide range of potentially harmful chemicals (EWG, 2005). Each of these potentially hazardous substances creates a health risk. Nurses need to understand the environmental exposures and the health effects that may be associated with chemicals.
Environmental Health Sciences
Toxicology
Toxicology is the basic science applied to understanding the health effects associated with chemical exposures. It is sometimes referred to as the “study of poisons.” Its corollary in health care is pharmacology, which studies the human health effects, both desirable and undesirable, associated with drugs. In toxicology, only the negative effects of chemical exposures are studied. However, the key principles of pharmacology and toxicology are the same. Just as the dose of a drug makes the difference in its efficacy and its toxicity, the quantity of an air or water pollutant to which we may be exposed can determine whether or not we experience the risk of a health effect. In addition, the timing of the exposure—over the human life span—can make a difference. For example, during embryonic and fetal development, exposure to toxic chemicals can create immediate harm or create a critical pathway for future disease. Very young children, whose systems are still immature, are also more vulnerable to exposures. Just as is true of medications, the same dose that one would give an adult will have a much greater effect on a child and certainly on a fetus.
Both drugs and pollutants can enter the body from a variety of routes. Most drugs are given orally and absorbed by the gastrointestinal (GI) tract. Water- and food-associated pollutants, including pesticides and heavy metals, enter the body via the digestive tract. Some drugs are administered as inhalants, and some pollutants in the air (including indoor air) enter the body via the lungs. Some drugs are applied topically. In work settings, employees can receive dermal exposures from toxic chemicals when they immerse their unprotected hands in chemical solutions, especially solvents. Pollution can enter our body via the lungs (inhalation), GI tract (ingestion), skin, and even the mucous membranes (dermal absorption). Most chemicals cross the placental barrier and can affect the fetus, just as most chemicals cross the blood–brain barrier. In addition to direct damage to cells, tissues, organs and organ systems, there can be changes to the DNA from chemical exposures that can change gene expression which, in turn, can predict disease. This latter effect is the focus of a relatively new biological study: epigenetics. Scientists now understand that there are many variables that predict disease outcomes including environmental exposures.
In the same way that we consider age, weight, other drugs taken, and underlying health status of a client when we administer drugs, we must consider that these same factors may affect the way in which individual members of the community respond to environmental exposures. For example, children are much more vulnerable to virtually all pollutants. People who are immunosuppressed (people with HIV/AIDS or those on immunosuppressant drugs like steroids or anti-cancer medications) and have autoimmune diseases are especially at risk for foodborne and waterborne pathogens. This includes people who are HIV/AIDS positive, who have been prescribed chemotherapeutic drugs, or who are organ recipients. Because our communities are comprised of people of different ages and different health statuses, their vulnerabilities to the effects of pollution will also vary. When assessing a community’s environmental health status, be sure to review the general health status of the community and to identify members who may have higher risk factors.
Chemicals are often grouped into categories or “families” so that it is often possible to understand the actions and risks associated with those groupings. Examples are metals and metallic compounds (e.g., arsenic, cadmium, chromium, lead, mercury), hydrocarbons (e.g., benzene, toluene, ketones, formaldehyde, trichloroethylene), irritant gases (e.g., ammonia, hydrochloric acid, sulfur dioxide, chlorine), chemical asphyxiants (e.g., carbon monoxide, hydrogen sulfide, cyanides), and pesticides (e.g., organophosphates, carbamates, chlorinated hydrocarbons). Although some common health risks exist within these families of chemicals, the possible health risks for each chemical should be evaluated individually when a potential human exposure exists. The best source of peer-reviewed information for this is the National Library of Medicine (NLM).
Epidemiology
Whereas toxicology is the science that studies the poisonous effects of chemicals, epidemiology is the science that helps us understand the strength of the association between exposures and health effects. Epidemiology is often used for occupationally related illnesses but has been used less often to study environmentally related diseases. It is difficult to characterize and/or distinguish from the many exposures that we all experience, and it can be challenging to find control groups when the environmental exposure of concern is in the air, water, or food.
Epidemiological studies have helped us to understand the association between learning disabilities and exposure to lead-based paint dust, asthma exacerbation and air pollution (Van den Hazel, Zuurbier, and Babisch, 2006), and GI disease and waterborne Cryptosporidia (Goldman, 2000). Environmental surveillance, such as childhood lead registries, provides data with which to track and analyze incidence and prevalence of health outcomes. The results of such analyses can help to target scarce public health resources. Scientists are now approaching epidemiology at the molecular level, looking at gene/environment interactions.
As described in Chapter 12, three major concepts—agent, host, and environment—form the classic epidemiological triangle (McKeown and Weinrich, 2000). (See Figure 12-2, A in Chapter 12.) This simple model belies the often complex relationships between agent, which may include chemical mixtures (i.e., more than one agent); host, which may refer to a community with people of multiple ages, genders, ethnicities, cultures, and disease states; and environment, which may include dynamic factors such as air, water, soil, and food, as well as temperature, humidity, and wind. Limitations of environmental epidemiological data include reliance on occupational health studies to characterize certain toxic exposures. The occupational health studies were performed on healthy adult workers whose biological systems were different from those of neonates, pregnant women, children, people who are immunosuppressed, and the elderly. Nevertheless, nurses can review epidemiological studies regarding exposures of concern to their communities and use epidemiological techniques to assess environmental risks in communities.
Another research tool for environmental health studies is geographic information systems (GIS), a methodology that requires the coding of data so that it is related spatially to a place on Earth. By combining such geographically related data, maps can be created to note where the data may be related. For instance, by taking a data set that geographically notes where children under 10 years of age live and overlaying another data set that notes geographical areas designated by the age of housing stock, a public health nurse could see where there are the largest number of children who live in areas with older housing stock. With this information, the nurse could target a lead surveillance and educational program. Nurse researcher Mona Choi used GIS to study the relationship between air pollution and emergency visits for cardiovascular and pulmonary diagnosis. Community-based maps that are created using GIS technologies are helpful in educating community members and local policy makers. The maps can provide useful graphic depictions of public health problems.
Environmental health requires a combination of tried and tested nursing tools mixed with new tools, such as GIS, and the recognition that many disciplines may be involved in the identification and the resolution of environmental health issues.
Nurse scientists Wade Hill and Patricia Butterfield developed a model for environmental risk interventions, which can be provided by public health nurses, that improves children’s health by addressing home-related sources such as lead paint, contaminated drinking water, and environmental tobacco smoke, among others. These risks can cause health effects ranging from minor learning deficiencies to serious and life-threatening diseases such as cancer. Many of the environmental risks children encountered were prevented or reduced by taking practical and affordable steps (Hill and Butterfield, 2006).
Multidisciplinary Approaches
In addition to toxicology and epidemiology, there are a number of earth sciences to help us understand how pollutants travel in air, water, and soil. Geologists, meteorologists, physicists, and chemists all contribute information to help explain how and when humans may be exposed to hazardous chemicals, radiation (e.g., radon), and biological contaminants. Key public health professionals include food safety specialists, sanitarians, radiation specialists, and industrial hygienists.
The nature of environmental health demands a multidisciplinary approach to assess and decrease environmental health risks. For instance, in order to assess and address a lead-based paint poisoning case, we might include a housing inspector with expertise in lead-based paint or a sanitarian to assess the lead-associated health risks in the home; clinical specialists to manage the client’s health needs; laboratories to assess the blood lead levels, as well as lead levels in the paint and house dust and drinking water; and then lead-based paint remediation specialists to reduce the lead-based paint risk in the home. We might also add a health educator and outreach worker to educate the family and encourage compliance with environmental health behaviors and clinical treatments. This approach could potentially involve the local health department, the state department of environmental protection, the housing department, a primary and tertiary care setting, and public or private sector labs. The nurse’s responsibility is to understand the roles of each respective agency and organization, know the public health laws (particularly as they pertain to lead-based paint poisoning), and work with the community to coordinate services to meet their needs. The nurse also might set up a blood lead screening program through the local health department, educate local health providers to encourage them to systematically test children for lead poisoning, or work with advocacy organizations to improve the condition of local housing stock.
Global Warming/Climate Change
Global warming and the associated long-term warming trends over the last century have been well established, and climate change scientists are projecting substantial disruption in water supplies, agriculture, ecosystems, and coastal communities. There are two concurrent categories of roles for nurses: mitigation and response. There is still much we can do to mitigate the steep upward slope that we are now observing for temperatures, CO2 levels, and sea water levels. Working at the individual, community, institutional (school, hospital, etc.), and governmental level, there is much work to be done to ensure energy-conserving policies and practices, rational transportation practices, and changes in our consumption patterns.
Regarding response preparation, public health nurses must lead the development of contingencies for long-term, high-heat weather conditions, as well as increased storm activities (that include more severe storm patterns) and the associated disaster preparedness. Nurses should also be prepared for threats to food security from shifting weather patterns that may not support food production as usual. Nurses should be prepared for population migration away from low-lying, coastal regions, creating a new type of refugee migration. The oil spill in the U.S. Gulf which was the largest in history has caused devastating damage to the Gulf of Mexico. It is expected that its effects on birds, fish, and other sea animals, as well as the environment, will last for many years to come. Since fish populations were affected, many fishermen have lost their jobs and the livelihood that they knew (Gulf Oil Spill, n.d.). This type of mobilization will be typical if the projections for global warming are not reversed.
Assessment
There are a number of ways to assess environmental health risks. For example, risks can be assessed by medium: air, water, soil, or food. In addition, exposures can be listed according to urban, rural, or suburban settings. Nurses may also divide the environment into functional locations such as home, school, workplace, and community. Each of these locations will have unique environmental exposures, as well as overlapping exposures. For instance, ethylene oxide, the toxic gas that is used in the sterilizing equipment in hospitals, is typically only found in a workplace. However, pesticides might be found in any of the four areas. When assessing environments, be sure to determine if an exposure is in the air, water, soil, and/or food and whether it is a chemical, biological, or radiological exposure.
Information Sources
The NLM has developed some of the most useful, comprehensive, and reliable sources of environmental health information. The NLM’s website for ToxTown (http://toxtown.nlm.nih.gov/) is one of the best places to start when developing environmental assessment skills. Within ToxTown, there is a new Household Products page where nurses can research common products such as personal care products, cleaning products, pet care products, lawn care products, and others to see the potential health risks that may be associated with them. Also, chemicals can be researched by brand or chemical name or by Chemical Abstract System number. (The NLM website can be accessed through the WebLinks feature of this textbook’s website or at www.nlm.nih.gov; at the website, search for the environmental assessment section.)
Another database that is specific to personal care products, which includes over 40,000 products that can be searched by brand name and specific product descriptors, is the Safe Cosmetics database (www.safecosmetics.org). This database provides information on how to protect your health such as by selecting products that have simpler ingredients and few synthetic chemicals and has a “skin deep” data base where readers can assess products for toxicity. For example, the site points out that even top selling brands of natural and organic products may have some toxic components. Specifically, they say that some top selling herbal shampoos contain 1,4-dioxane which is a synthetic chemical carcinogen. They also comment on the number of lipsticks that they found to contain lead. Note that in both the NLM and the Safe Cosmetic databases, the information is predicated on what the manufacturers place on the label as ingredients. If the manufacturer claims that a component is a “trade secret,” it will not appear on the label. Rarely are the chemicals that make up a “fragrance” listed on the label; instead, it is likely to only read “fragrance” on the label. And finally, especially with pesticides, the label may merely say “inerts” without any further information regarding their chemical identify. Thus, it is sometimes impossible to make a true assessment about the health risks based on the information provided by the manufacturer.
As seen in Box 10-1, one of the ANA Environmental Health Principles is the tenet of the “Right to Know,” which recommends the need for access to all information needed to make informed decisions and protect our health. There are still a number of ways in which full disclosure of chemical exposure is lacking in terms of air and water pollution, food contents, and product ingredients. Nurses can be advocates for increasing access to information through legislative and regulatory efforts both individually and through their professional organizations.
HOW TO
Apply the Nursing Process to Environmental Health
If you suspect that a client’s health problem is being influenced by environmental factors, follow the nursing process and note the environmental aspects of the problem in every step of the process:
2. Diagnosis. Relate the disease and the environmental factors in the diagnosis.
3. Goal setting. Include outcome measures that mitigate and eliminate the environmental factors.
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