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New App to Help Assess Environmental Health Risks

What Works & What Doesn't
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The EApp is a software application available for download on a mobile device, developed to facilitate environmental health assessment in home environments by healthcare providers. The EApp enables home healthcare providers to utilize local, geographically specific, publicly available, environmental health data to guide conversations with patients using queries, prompts, and suggested patient interview topics. The EApp additionally supports healthcare providers through the provision of a resource database for local environmental health services to which patients can be referred. 

On average, 75 percent of all medical schools require 7 hours of environmental health training over the course of 4 years.1 Fewer than half of all pediatric medical programs routinely include environmental health issues in their curriculum, other than asthma exacerbation and lead poisoning. Statistics for the number of hours of environmental health curriculum for nurses are lacking. One survey of undergraduate pediatric nursing faculty revealed that 59 percent of programs reported 2 hours or less in pediatric genetics, environmental health or nutrition content.2 In her 2002 article, Butterfield introduces the concept of “upstream thinking” to the nursing profession, which “considers the social, economic, and environmental origins of health problems that manifest at the population level.”3 Further, Butterfield introduces the many ways that nurses can and should engage with the root causes of these health problems, including tracking data, translating research, etiologic research and advocacy. 

However, the general lack of comprehensive environmental health and environmental health assessment training in the health sciences currently still contributes to lost opportunities for home healthcare providers to intervene and prevent disease early. Illnesses of environmental origin may appear in small clusters, making it more difficult to fund large-scale studies to better understand the biological or social mechanisms at work. Preventing exposures at an early stage can lead to lifelong benefits as well as healthcare cost-saving. Exposure to environmental hazards may directly affect an individual’s health, and indirectly increase healthcare costs. In 2008, the U.S. spent $76.6 billion on diseases of environmental origin in children, or about 3.5 percent of U.S. healthcare costs.4

Home healthcare nurses currently do not include environmental assessment as a standard of care, which means that environmental contributors to disease are assessed irregularly, voluntarily, and, therefore, only for some patients. Medical and nursing education programs lack the environmental health content needed to properly prepare healthcare professionals to assess for, prevent, recognize, manage, and/or treat environmental exposure-related diseases. A growing number of community-based and home health programs are compelled by financial pressure or policies to focus more effort and resources on preventing disease, yet programs continue to be challenged to find affordable and effective solutions. The most environmentally polluted areas are often also the poorest, leaving those who are already disproportionately burdened by pollution without adequately prepared home healthcare providers. As community violence, climate change-related super-storms or municipal water issues like chromium 6 or the Flint Water crisis become more pressing, the need to address health concerns with environmental origins is also rising. 

Poor environmental quality is estimated to be directly responsible for approximately 25 percent of all preventable illness in the world.5 The environment is a determinant of health, yet healthcare providers who work in homes and communities are not currently equipped to take geographically relevant, environmental information such as indoor air quality, housing quality, waste issues, pollen count, arsenic or radon pervasiveness, crime, industrial or agricultural activity, air pollution, Brownfield or Superfund site proximity, etc. into account when assessing the health and wellbeing of their patients. Further, if a potential environmental contributor to disease is discovered, home healthcare providers must currently develop their own list of local resources (such as lead abatement programs) to refer patients to. Individually developing such a list of resources is time-consuming, cumbersome, and voluntary. 

The EApp is a software application available for download on a mobile device such as an iPad or iPhone, developed to facilitate environmental health assessment in home environments by home healthcare providers. The EApp enables home healthcare providers to utilize local, geographically specific, publicly available, environmental health data to guide conversations with patients using queries, prompts, and suggested patient interview topics based on the environmental data available. The EApp additionally supports healthcare providers through the provision of a resource database for local environmental health services to which patients can be referred. This resource database encourages providers and patients to access local resources to assist with the prevention of potential contributors to disease. The app further provides an online professional forum and live chat to assist healthcare providers with content-related questions. 

The 2010 American Nursing Association (ANA) Scope & Standards of Practice includes an Environmental Health Standard of Practice. Based on environmental health assessment tools such as those previously developed by the National Center for Healthy Housing, the Physicians for Social Responsibility Pediatric Environmental Health Toolkit, the HUD Healthy Homes Initiative, and including data sources such as Environmental Score Card, National Environmental Public Health Tracking Network, and TOXNET, EApp brings together all of the data and education tools that home healthcare providers need to provide meaningful environmental health assessments and interventions for patients in their homes. The EApp facilitates the further implementation and embedding of the ANA environmental health standard into daily practice. 

Approximately 12,200 U.S. home health agencies could benefit from the deployment of EApp in the communities they serve.6 Two million home healthcare workers across the United States in geographically and demographically diverse communities could benefit from the adoption of the app. Close to 4.7 million patients received home healthcare at any time during the year and could benefit from the addition of environmental assessments during the course of their care. Membership subscription sales would be the most direct way to track the engagement with this tool. 

Currently, there are no known similar tools with which EApp can be compared. The app draws from publicly available data in geographic context, which is important for the useful assessment of dynamic environmental problems. It provides environment-related interview questions, which are also not regularly included in assessment or documentation forms carried by home healthcare providers. Future iterations of the app can collect pertinent environmental data in tandem with data about symptoms. The data collected could be integrated with existing data pools (such as those maintained by the Centers for Disease Control and Prevention), furthering the study of correlations between environmental context and health. Based on research conducted, it appears that there are no other similar mobile technology tools for home healthcare providers. There are, however, several platforms or tools that are somewhat related, such as the CDC’s National Environmental Health Tracking Network, TOXNET (National Institutes of Health), or the Environmental Protection Agency’s EJSCREEN environmental justice mapping tool. The EApp could eventually contribute to or be integrated into an appropriate governmental website. 

Familiarity with the “Environmental Justice” community of Chester, PA and following nurses from the Nurse Family Partnership during home visits to low-income, first-time mothers in that community underscored the need for environmental assessment. Pregnancy and the first years of life are particularly susceptible developmental phases during which environmental factors can impact health and wellbeing. This community and these nurses provided one example for how environmental assessment could contribute to the efficacy of home healthcare. In addition, anecdotally, home health nurses have indicated the need for a local referral database that helps them to refer patients to good resources to ameliorate environmental concerns in the home. 

EApp’s primary revenue will come from annual platform subscription fees that can be purchased by individuals or by organizations. EApp is being designed to be used as a DIY product; however, training on environmental health assessment is currently planned as a parallel product offering. The primary target market for EApp is U.S.-based public and home healthcare agencies. The app will work best for an agency that builds longer term relationships with patients. During the first phase of development, the EApp will specifically focus on RNs within these agencies. Phase 2 of app development and environmental health assessment training would extend the reach and utility of this app to a variety of other professionals, including social workers, midwives, and nursing assistants. Larger agencies or those with a national reach enable the aggregation of more (and therefore more robust) patient data, allowing agency management to incorporate environmental health preventive interventions with greater confidence and with greater impact.

EApp addresses social and environmental justice. Low-income populations are disproportionally affected by environmental exposures, and ultimately, the economic costs are disproportionately borne by these same sections of society. Yet, many of the individuals residing in low-income communities are not actively assessed for, educated about, or protected from potential environmental exposures. By conducting a patient interview with environmental factors in mind, home healthcare providers can enable families in polluted communities to take positive steps to prevent health problems, and to incrementally enhance the health of their most immediate surroundings, the home environment. The data collected can make the problems faced by these communities more visible and accessible to policymakers and to researchers. Risks presented are few, and may include over-reliance by healthcare providers, as a replacement for their own nursing assessment ability, and the potential for breach of privacy for patients. 

Aside from addressing the needs of the most vulnerable populations, the EApp can also be used to optimize health and wellbeing of individuals who are already healthy. By assessing for environmental risks, those individuals are enabled to further enhance and protect their health. Optimizing the health of already-well individuals can contribute to our knowledge about which factors keep populations healthy. Already-well individuals also represent another market for the app. 

References

1. Bonnie Rogers, Leyla Erk McCurdy, Katie Slavin, Kimberly Grubb, and James R. Roberts, “Children’s Environmental Health Faculty Champions Initiative: A Successful Model for Integrating Environmental Health into Pediatric Health Care,” Environmental Health Perspectives 117, no. 5 (2009): 850, doi: 10.1289/ehp.0800203.

2. Ann Marie McCarthy and Janet S. Wyatt, “Undergraduate Pediatric Nursing Education: Issues, Challenges and Recommendations,” Journal of Professional Nursing 30, no.2 (2014): 130, doi: 10.1016/j.profnurs.2013.07.003.

3. Patricia G. Butterfield, “Upstream Reflections on Environmental Health: An Abbreviated History and Framework for Action,” Advances in Nursing Science 25, no.1 (2002): 32.

4. Leonardo Trasande and Yinghua Liu, “Reducing The Staggering Costs Of Environmental Disease In Children, Estimated At $76.6 Billion In 2008,” Health Affairs 30, no. 5 (2011): 3, doi: 10.1377/hlthaff.2010.1239.

5. “Health Topics, Environmental Health,” World Health Organization, accessed October 16, 2016, http://www.who.int/topics/environmental_health/en/.

6. “National Center for Health Statistics, Home Health Care,” Centers for Disease Control and Prevention, accessed October 16, 2016, http://www.cdc.gov/nchs/fastats/home-health-care.htm.

Author Bio
Erin Johnson is an Assistant Clinical Professor at the Drexel University College of Nursing and Health Professions. Professor Johnson holds BSN (2009), MSN and MPH (2010) degrees from the University of Pennsylvania. She earned a BA in Environmental Studies from Washington University in St. Louis, Missouri (1997), during which she attended a semester abroad on Sustainable Development in Costa Rica (1995, School for Field Studies). For Professor Johnson's MPH capstone project, she researched the environmental health assessment and data collection practices of home healthcare nurses in Chester, PA. 
With strong interest in prevention of illness, the promotion of health and how environmental determinants impact health, Professor Johnson has worked and volunteered in a variety of settings related to health and the environment. She has served as Vice Chair of the Pennsylvania State Nurses Association Environmental Health Committee, volunteered with Puentes de Salud public health clinic, directed over 200 public programs on environmental sustainability, and has worked with a variety of related community organizations and initiatives in the Philadelphia region.