PACE EH Online Course Module 3

During Tasks 7–9, the team is instructed to begin developing viable indicators for a select number of the remaining priority issues (between 10 and 20). The development of indicators is simply moving from the qualitative efforts in Task 6 to quantitative measurements that will carry the process forward.

PACE EH puts indicator development before data investigation. In other words, we ask the teams to build indicators before establishing the existence of data to support or refute the use of the indicator. Keep in mind, if the indicator your team decides on has no supporting data, you have the start of a great action plan staring you in the face.  

At the completion of this task, the assessment team should have:

  • An agreed-upon list of indicator selection criteria.
  • A set of key environmental health indicators.

The mapping process in Task 6 analyzed and described the qualitative relationship among components of an environmental health issue. Task 7 translates that information into quantitative measures through the development of indicators.

What Are Indicators

Indicators are tools for quantifying, through direct or indirect measures, a significant aspect of an environmental health issue. They may be used to describe and communicate overall environmental health status and to track trends. In the PACE EH process, indicators are used in developing issue profiles (Task 9), ranking and prioritizing the community’s environmental health concerns (Tasks 10 and 11), and ongoing evaluation (Task 13).

Due in part to local variability, scientific uncertainty, and differing values, there is no national or scientific consensus on a set of environmental health indicators that are most appropriate for use in all communities. This section therefore guides the user in developing environmental health indicators that reflect local conditions and concerns.

Development of an indicator list is one of the most important aspects of the assessment process for ensuring long-term success and results, for several reasons:

  • Local environmental health assessment and the process of measurably improving local status are most effective and best supported over the long term when meaningful measurements are available to help define areas of concern and to mark change. 
  • Well-developed and clearly communicated indicators will help sustain the effort, despite inevitable turnover among participants.   
  • The process of establishing indicators will highlight any pre-existing issues related to the availability of and the quality of locally useful data. It can also draw attention to the need for improved or increased data collection as a local priority.   
  • Many members of the public, including local policy-makers, respond best to a simple, clear, easy-to-understand message. A good indicator with reliable data is a very effective communication tool for this audience.

Develop a List of Potential Indicators

It may seem that the identification of indicators should come after the collection of data (Task 9). However, relying on existing data to dictate the scope of a community’s environmental health assessment is far too limiting. From a philosophical standpoint, it is important that community values and concerns, not the availability of data, drive the development of indicators.

Example: Lead Poisoning

One possible gap in the “web” may be high blood lead levels in children raised in “safe” housing. The gap is the route of exposure. A viable indicator may be “How many children with elevated blood lead levels live in safe housing but play on playgrounds with equipment dressed with lead-based paint?” Do those figures represent a significant environmental health problem? Can you begin to see how a valuable environmental health action plan might emerge from this process?

Identify Key Indicators Based on Selected Criteria

The previous step likely generated a lengthy list of options for possible indicators. The job now is to select from among these and choose a few that are robust and effectively describe the key elements of concern related to an environmental health issue. Selection criteria will facilitate this process. Use selection criteria to “screen” possible indicators. The following is a list of suggested criteria for selecting indicators of environmental health status. Consider amending this list to reflect the community’s values and interests.

Indicator Development

Pilot site teams approached the indicator development stage in a variety of ways. One team generated reports containing basic information about human health effects, causes/contributors, pathways, and current public health protection factors, related to the issue under investigation. The team then organized three technical “subcommittees” to consider and report back on potential measurements (indicators) related to the issues and to choose three or four indicators they considered most meaningful locally. These were compiled into a “B” list of indicators. 

After discussion with the team, each subcommittee was tasked with choosing one or two “primary” indicators for each issue. These were compiled into an “A” list of indicators. In general, indicators were included on the “A” list only if data were currently collected and were available. Where data were not being collected or made available, the item was added to a “Data Wish List.” The assessment team intends to circulate the wish list to relevant agencies and individuals to encourage increased data availability and development of new data sources.

Questions to Consider

What are indicators?  Why is it important to develop local environmental health indicators? Why should development of indicators before identification of existing data?

At the completion of this task, the assessment team should have:

  • Appropriate standards—national, state, local, and community-driven—against which environmental health status can be compared.

The next step is to determine what the indicators tell about the relative status of the community’s environmental health. Standards, or benchmarks, provide a point of comparison for the community’s environmental health status. They may come from the state or national level, from a peer community, or from the community itself as it seeks to document attainment of goals over time.

Identify Externally Driven Standards

As with indicators, there are no nationally agreed-upon standards for local environmental health status. Two widely used standards in the public health community are:

  1. Healthy People 2020—Improving the Health of Americans.
  2. Healthy Communities 2000—Model Standards (APHA, 1991).

Additionally, the U.S. Environmental Protection Agency developed environmental goals and benchmarks for 2005 (U.S. EPA, 1996). Although these publications may be helpful for broad community health application, neither is particularly robust in environmental health or reflective of community-developed priorities. In the absence of other standards, these resources may be useful in providing a national context.

Agree upon Locally Appropriate Standards

Ideally, standards used to interpret local status (and benchmarks used to track progress) should reflect community-based goals and values. Community-driven standards can be derived from the work completed in Tasks 7 and 9. The assessment team can review the selected indicators, irrespective of existing data, and agree upon acceptable or desired data points to describe the issue. These then become standards that can be used (in Task 9) to determine whether actual community data calls for significant attention to be paid to the issue. Similarly, indicators complete with data representing current status can serve as benchmarks (or starting points) against which progress over time can be demonstrated. These can be used to determine if public health protection factors or other intervention activities are, in fact, effective.

Note: A local standard is not an end in itself. It can, and should, be changed over time as a community’s environmental health status changes.

Questions to Consider

Why is it important to select standards or benchmarks? What is one of the most widely used external standard?  What is a widely used source for national EH standards? and Why should EH standards reflect community-based goals and values?

At the completion of this task, the assessment team should have:

  • Developed profiles for each environmental health issue 
  • Adopted a standardized format for organizing information 
  • Gathered information 
  • Developed a summary statement about locally relevant EH issues

Format

This task results in a profile for each identified issue. Profiles are simply a way to format information into succinct narrative reports. These reports will be used in Task 10 to rank the community-specific environmental health issues.  The profiles can be prepared by one person, or the responsibility can be divided among team members, community volunteers, professional staff, and/or students. It is important to create a uniform format for the profiles. Whatever the process, the goal is to generate a comparable set of information about each issue.

Gather Information

The team will collect comparable information on each issue which may list information known to the local health agency and other organizations/institutions represented on the assessment team, as well as impressions gathered through community-input efforts, related to the issue. By listing relevant standards, the team compiles local and national data reflecting both the current and the desired status of the issue.

Issue Profile Development

Preparation of issue profiles represents an excellent opportunity to spread the work of the assessment across team members. There will likely be several assessment team members who are authorities in specific scientific or technical fields and who can prepare a profile fairly easily. (Some of these experts will be local health agency staff who might not be directly involved as team members.) What is the health official’s role at this stage, aside from coordination? It is quite useful for someone to serve as a non-technical editor of profiles and ensure clarity for other non-expert team members or to the general public.

Environmental and Public Health Data Sources

Keep in mind however, data gathering takes considerable time and effort. Work with a range of local, state, federal, and private agencies to obtain the most recent community-specific data. Familiarize the team with the limitations of environmental health data. For example, data collected for other purposes may not be applicable to the environmental health context.

Mortality Data

These data provide the initial basis for assessing the health of the community. They can be obtained from state and local health agencies. Typically, incidence data are provided for each cause of death, and the total number of deaths by cause is expressed as a percentage of total deaths in each of nine age groups. Secondary contributors to death (e.g., workplace exposures) may not be noted.

Reportable Disease Data

Reportable disease data are also available from state and local health agencies. Reporting requirements differ from state to state, and not all reportable diseases have environmental implications. Find out about reporting requirements in the target community, and try to obtain at least five years of data for diseases that may be related to environmental exposures or endpoints. Evaluate and interpret trends or variations in annual incidence.

Hospital Discharge Data

Hospital discharge data constitute an important source of morbidity information. Aggregated data sets usually provide information on age, race, sex, method of payment for services, and length of hospital stay. Unfortunately, not all states or hospitals collect discharge data. If the data are available, they will be coded by the International Classification of Diseases (ICD) system. A list of codes for community-acquired diseases and sentinel occupational diseases from the Ninth Revision of the International Classification of Diseases (ICD-9) is provided in Appendix F of the PACE EH guidebook.

Injury Data

Injury data may be available from hospital emergency departments, state and local transportation departments, and emergency medical and ambulance services. Surveillance data are collected using standardized ICD-9-CM E-code categories. A listing of E-codes relevant to community-based environmental health assessments is provided in Appendix G. In addition, the Consumer Product Safety Commission (www.cpsc.gov) collects national data about injuries linked to specific products. Information on unintentional poisonings is available from local or regional poison control centers.

Data on Environmental or Quality-of-Life Endpoints

When the community’s environmental health status is described in terms of quality-of-life and ecological outcomes, morbidity and mortality data will need to be supplemented with data that reflect physical, biological, and even social attributes (e.g., information on pollutants, land use, endangered species, open space and parks, surface water quality). Data sources will therefore extend beyond health agencies to other levels of government and other sectors.

Affected Populations

The most accessible and detailed information sources on populations are the U.S. Census of Housing and the U.S. Census of Population. These provide statistics on households and individuals aggregated in most cases by block or census tract, as well as by zip code, town, state, and nation. Hundreds of demographic data fields (e.g., age, ethnicity, income) as well as behaviors such as commuting times and shopping are included. Census data are available in hard copy, on CD-ROM, and online (www.census.gov).

The information is limited, however, by the 10-year intervals between data collection periods.  
Other data sources on high-risk populations include the various departments and institutions that work with specific groups (e.g., schools, prisons). If national data do not provide an adequate level of detail, try state agencies or municipal departments of planning, taxation, or community development.

Exposure Dynamics

Look for information on exposure factors in the literature on that topic or from professionals in the field.

Environmental Agents/Conditions

Data on environmental agents and conditions are available from the EPA and state/local environmental agencies, natural resources agencies, pollution control agencies, and health departments.  

EPA maintains several monitoring systems to track ambient pollutants in water and air:

  • Data on water quality are provided in the biennial State of the Nation’s Waters, a compilation of reports required of each state under the Clean Water Act.
  • Ambient air monitoring and emissions data are compiled in the annual Air Quality and Emissions Trends Report.
  • Data on ambient air quality (concentrations of six major “constituent pollutants”), collected via a national network of monitors, are available from the Aerometric Information and Retrieval System (AIRS).
  • Data on drinking water are derived from state Safe Drinking Water Information System (SDWIS) databases, which include information on violations of drinking water standards for levels of selected contaminants.

Note: Most of the national data sets are based on reports from states, municipalities, or even individual facilities. If the level of detail is inadequate, seek more specific data from the corresponding state or local agencies. Other sources of data on local conditions include the municipal or state agencies with responsibilities for particular agents such as waste or noise. Private organizations and institutions also might collect data for specific purposes; for example, a local land trust might maintain an open space inventory or database of forest cover.

Other Data Sources

A wide range of factors might contribute to a particular environmental health issue. Data sources therefore will be similarly diverse. Direct factors, such as emissions of pollutants into the environment, can be described by use of EPA data collected under various regulatory programs.

Potential sources are the Toxics Release Inventory (an annual report from selected industrial sectors on release and transfer of certain chemicals) and the annual Air Quality and Emission Trends Report.

Note: The local public health agency should be able to identify key information sources for environmental health data and assemble a description of the type and quality of information available. Most other state and municipal agencies maintain some measure of their own activities (e.g., permits issued, compliance rates, number of training seminars conducted) or of community actions (e.g., recycling rates, carpooling statistics). When thinking beyond governmental responses, consider what organizations or groups in the community might be involved in certain activities. For example, a litter cleanup program might track the number of volunteers or the amount of trash picked up; a YMCA might document the utilization of its educational offerings or outreach programs.

Questions to Consider

Why is it important to develop a standardized format for organizing information?  What are two sources for environmental or public health data that may be useful in creating issue profiles? (Does not have to be resource listed here.)  Is it possible to create issue profiles when there is little or no data to?