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Environmental Influences in Community Health Care

Environmental Influences in Community Health Care

Chapter 13

Overview. Sources of environmental hazards. Environmental issues for the 21st century. The nurses responsibilities in primary, secondary, and tertiary prevention. The future of environmental health nursing.

Understanding the effect of environment factors on health and disease requires a social, cultural, political, economic and physical forces interact with the psychological rhythms that form the foundation of human existence. Environmental health is one of humanity's oldest concerns Prehistoric times, people often attributed disease to their gods and therefore sought to pacify these gods.

The Hippocratic concludes that the wellbeing of man is influenced by all environmental factors : the quality of the air, water, and food, the wind and the topography of the land. Great Roman Aqueducts and highly developed sewage system are testaments to their concern about the spread of disease.

Environmental improvement and effort toward the control of communicable disease continued in the 20th century with wide spread use of immunization and the discovery antibiotics Then Florence Nightingale identified the need for a clean environment; she outlined five essential points in securing the health of houses; "pure air, pure water, efficient drainage, cleanliness and light.

20th the nurse programs, principles of public health and community hygiene were including curriculum. Topics including "sanitation of food and water, sanitation system for sewage disposal, adequate housing, the control communicable disease, community health problem in child bearing and childhood and organization of public health services to maintain health (Grander ; 1936)





Definition of Environmental Health by WHO 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.

Definition of Environmental Health by National Institute of Environmental Health Sciences Environmental health is the branch of public health that is concerned with all aspects of the natural and built environment that may affect human health. The priorities of the Environmental Health lie in areas related to contamination of the environment and the possible adverse effects of environmental pollutants on human health.

A conceptual Model of Ecological System

1. Micro Systems

Are closest to the human population, the micro systems includes : The environment immediately surrounding the person (e.g. the family and the home). Environment constitute the macro system.

A conceptual Model of Ecological System

2. Macro System

Is the largest context in which the micro system is embedded. Culture, traditions, customs, societal, norms, government, economic policies, and physical

Sources of Environmental Hazards


Environmental Hazards at Home 2) Environmental Hazards in the Occupational Setting 3) Environmental Hazard in the Community

Sources of Environmental Hazards

1. Environmental Hazards at Home Poisoning: is the major cause of accidental death (lead poisoning, Pesticide poisoning, Mercury poisoning, Carbon Monoxide poisoning)

Environmental Hazards at Home

Falls: falls is the other major cause of accidental death most such accident happen in the older (poor light, loose electric cords and rugs). In children, windows that do not have guards are hazard.

Environmental Hazards at Home

Burns: fire and burns are third highest cause of home death Suffocation and Drowning: are a serious causes of accidental death nearly 800 reported death in USA in 1995. Firearms: it occur annually while people are playing with or cleaning firearms, the number highest for the 15-24 year old group. and it increased to double in suicidal and more in homicide


Environmental Hazards at Home

A potential source of disease that often taken for granted is the method of garbage disposable. Gaza strip produced 0.68 MCM solid waste . Garbage lead to contamination of water supplies contribute to breeding of bacteria and virus that can transmitted to humans via insect and rodent and possible serve as reservoir for disease "gastroenteritis, hepatitis, polio".

Radon: radon has been of great concern in recent years. radon is an odorless, colorless and tasteless radioactive gas that is the by product of the decay of uranium it occur natural in the soil.

Environmental Hazards at Home

Lead: lead poisoning is one of the most significant public health achievement in recent years (see table1)... Lead - based paint, including dust and chips, airborne from steel structure, contaminated

Table 1: Lead Poisoning And Symptom Effect

9 g/dl Tranplacental transfer, minimal observable effect 10-20 g/dl cause toxicity, affect on growth, hearing, IQ.

Table 1: Lead Poisoning And Symptom Effect

21-44 g/dl
vitamin D metabolism, Hb synthesis, mild fatigue 45 - 69 g/dl Myalgia, irritable, lethargy, gastrointestinal complaint 70 g/dl paralysis, encephalopathy, coma, seizure, colic

Formaldehyde: including carpets, draperies, shampoos, and cosmetics. Carbon Monoxide: is a colorless and odorless gas that is a byproduct of combustion. sources are improperly vented furnaces, blocked flues or chimneys and automobile exhaust, CO can cause dizziness, headache, drowsiness, nausea, or flu- like symptom. Environmental Tobacco Smoke: a major source in door air pollution is environmental tobacco smoke. tobacco has been recognized as causes of lung cancer and other respiratory diseases in smoker.

Implication for Nurses Promotion health and prevent illness some time primary prevention, involve education people to eliminate hazard before exposure occur. Secondary prevention or screening for environment hazardous

Key Area To Assess In The Home Environment

Neighborhood: Proximity to industry, highways, land fill, availably of basic service (health care), transportation, population density, and noise. Physical structure: Cracks in foundation or window, peeling paint, stair.

Safety issue: Storage for medication, cleaning supplies, chemical, firearms, emergency escape, locks on door, outside play area. Sanitation: water and sewage system, laundry, rodent, pets, and insect. Space: Sleeping area. privacy for members of household and lighting. Temperature regulation: type of heat and air condition and types of insulation

2. Environmental Hazards in the Occupational Setting

Environmental hazards in the occupational setting are characterized by a wide range of health and safety hazard that may result in the occurrence of occupation injuries and illness.

Top occupation illness:

1. Disorder with repeated trauma 2. Skin disease and disorders 3. Respiratory disease caused by toxic agent 4. Poisoning 5. Dust disease of the lung.

Role and Function of Occupation Health Nurse

Promotion, protection, and maintenance of the health and safety of workers. Emphasis on wellness and life style changes in addition to reduction of risk associated with environment exposure.

Description of Roles of Occupational Health and Safety Specialist

1. Toxicologist: studies and describe the toxic prosperities of agent used in work application to which worker may expose 2. Industrial hygiene: control and evaluation toxic exposure and hazard in the work environment.

3. Occupation physician: focus on prevention, detection and treatment of work related to work disease and injuries 4. Safety specialist: including safety engineering and other safety professional also focus on prevent of occupation disease and injuries 5. Ergonomist: studies, designs and promotes the healthy interface of humans, their tools, and their work. 6. Epidemiologist: studies describe the natural history of occupational disease and injuries.

Responsibilities of the OHN

Primary care provider. Counselor. Advocate / liaison. Administrator Educator. Monitor. Professional member of the health team. Researcher.

Environmental Hazard in the Community


Chemical hazard
Insulation (formaldehyde CH2O): expected harmful effect (respiratory allergies) 2. Automobile exhaust (lead): expected harmful effect (behavior disorder, neurological symptom) 3. Pesticides (polychlorinated biphenyls {PCB}): expected harmful effect (Chloracne, liver disease)

Biological: (Infectious)
1.Water supply (Giardia lamblia): expected harmful effect (diarrhea, bloating, mal absorption) 2.Food (Salmonella): expected harmful effect (fever, nausea, diarrhea) 3.Mosquito (Malaria): expected harmful effect (fever, chill)

1. Physical hazard (faulty construction): expected harmful effect (death or injuries) 2. Noise (motor vehicles i.e. airplanes, cars, motorcycle) expected harmful effect (hearing problem stress fatigue) 3. Radiation (radon gas): expected harmful effect (infertility, birth defect, leukemia).

1.Natural disaster (e.g. flooding): expected harmful effect (hypertension) 2.Low economic status (unemployment): expected harmful effect (heart disease, ulcer) 3.Multiple role demand (working parent): expected harmful effect (depression, anxiety).

Environmental Issues for the 21 st Century

1. 2. 3. 4. Clean air and water Air pollution Water and soil pollution Hazardous wastes.

The Nurse's Responsibilities

Primary prevention Advocate safer environment design of product, automobile, equipment and building Teach home safety relate to falls and fire.

Counsel woman of child bearing Develop work site health and safety program Advocate vehicle protection system such as seat belt. Immunization occupationally exposed worker for hepatitis B Support programs for waste education and recycling

Secondary prevention
Assess home, schools, worksites and communities for environmental hazard Screen children from 6 month to 5 years age for blood lead level Monitor worker for levels of chemical exposure Screening at risk worker for lung disease, cancer and hearing loss.

Tertiary prevention
Encourage limitation of activity when air pollution is high. Support cleanup of toxic waste sites and removal of other hazards. Refer homeowners to approved lead abatement resource

Environmental Health in Gaza Strip

Each student should write report abut environment Gaza Strip

Background of Environmental Health in Gaza Strip Gaza Strip is a semi-arid region of roughly 365 km2 which lies on the Mediterranean Sea. On this narrow strip, almost 1.4 million of the Palestinian people live and work. A " Catastrophic" water shortage, water pollution with high salinity and micro-pollutants, lack of sewage and solid waste treatment, maritime pollution, overcrowding, poverty and uncontrolled use of pesticides are the most pressing environmental problems in Gaza Strip. Internationally suspended, banned and canceled pesticides which considered mutagenic and carcinogenic are still used in the agricultural environment.

Mediterranean Sea is used for the disposal of sewage water, solid wastes, agricultural and industrial waste water.
In general these environmental problems have multiplied the Palestinians human environment problems, socioeconomic problems and increasing health hazards. Therefore, the environment in Gaza Strip requires a more thoughtful and comprehensive policy and planning of awareness and conservation.

Importance Water is one of the essential components of the human body. It plays active role in the physiological process that is necessary to human life. Water is essential for heat regulation, acid-base balance, excretions to toxins and waste material and metabolism of all food material. Sources of water The underground water is the main source of water in Gaza Strip. Wells are used to get the underground water.

Raining water is used in West Bank. The water is collected in private store under each house. The family uses this water during all the year. Surface water could be from rivers or lakes. Tabria lake is one of the main water store in Palestine.
The main source of water in Gaza Strip is the ground water (about 5000 well) which is used for irrigation, industrial and domestic purposes. The consumption about 120 MCM / year and the recharge about 70 MCM /year. In Fact, per capita water consumption in Gaza Strip is less 4 5 times other countries. This has led to the depletion of available quantities in Gaza Strip and reduction of ground water storage as well as the degradation of water quality.

Water Characters:
1- Physical: the water should be colorless, tasteless and odorless. Change of odor, color or taste indicates water pollution or contamination. 2- Biological: Drinking water should be free from all microorganisms. The best indicator for water contamination is the presence of E. Coli indicates fecal contamination. 3- Chemical: The accepted level of chemical concentration is referred to the maximum concentration of specific material in water that if exceeded it will endanger human heath .

Water pollution Types of water pollution: 1- Organic wastes from domestics. 2- Infectious agents contributed by domestic sewage. 3- Plant nutrients as algae. 4- Synthetic organic chemicals as pesticides, detergents etc. 5- Inorganic chemicals and minerals substances. 6- Sediments that fill stream channels and reservoirs. 7- Radio active pollution

Health Hazards of Water

Water Sources in Gaza Strip are subjected to excessive over- exploitation and over - pumping , this has led to degradation of water quality in Gaza Strip , where severe water shortage (about 50 MCM / year) are experienced and where the situation has become catastrophic.
Water Pollution with different pollutants (Salinity such as Chloride and Nitrate and Micro - pollutants such as Pesticides, Fertilizers & Detergents). For example chloride and nitrate concentration in some wells reaches more than 1500 and 100 ppm respectively.

Palestinian and German scientists have recommended to the Palestinian Authority to take immediate measures to combat excessive nitrate levels in the drinking water. 90 % of Gaza Strip water samples were found to contain nitrate concentrations that were between two and eight times higher than the limit recommended by the (WHO). Over the long term they recommend that the best protection would be provided by quality management for groundwater resources. In babies younger than six months, nitrate can lead to methaemoglobinaemia, to diarrhoea and to acidosis. The WHO recommends keeping nitrate levels to 50 mg/ L or less.



Gaza Strip produced about 35 MCM / Year sewage water. Unfortunately about 50% the raw sewage is discharged untreated in the Mediterranean Sea where the biological oxygen demand increases.

The rest of sewage is collected in three central sewage collecting pools with semi treatment such as the first step of primary treatment which is the aeration and sometimes the secondary treatment. When these pools filled with sewage water, it's flooded aside and pollutes the ground water because our aquifer is shallow.

Sewage networks cover no more than 70 % of total residential areas in the Gaza Strip. So far, there is no adequate sewage collection and treatment facilities where use of septic tanks to drain waste water is still widespread thus causing, through leakage , the contamination and pollution of the aquifers and increasingly saline. Open sewage channels spread in some parts of the Gaza Strip, particularly in refugee camps, creating health hazards through the accumulation of garbage and wastes. The situation is so dramatic that during a visit to the West Bank and Gaza Strip in January 1988, the British Minister of the Foreign Office David Miller described the situation in the Occupied Palestinian Territories as being an affront to civilized values.




Waste water disposal is of great importance for population health because of the main link between human excreta and transmission of disease from one person to another. It is important that adequate disposal measures are applied to control this method of disease transmission. All liquid wastes should be handled properly in a sanitary manner. Industrial wastes are a special problem endangers the health of communities if not managed properly.

Health Hazards of Waste Water * Disease transmission: most of enteric diseases could be transmitted from one person to another through contaminated environment such as Cholera, Typhoid, Dysentery, Parasites, polio and Hepatitis. * Bad smell resulted in psychological disturbance. * Sewage collection is a breading place for insects as mosquitoes and flies. * Contamination of underground water by biological and chemical pollutants.
Management of Sewage: Treatment: Biological treatment is performed by these mechanisms: a. Filtration b. Aeration ( ) , c. Disinfection

Solid Waste
Gaza Strip produced about 0.68 MCM/Year solid waste. There are no enough dumping sites, sanitary landfills, containers and vehicles. Therefore, the solid waste is sometimes thrown everywhere. Gaza Strip utilizes the old method of landfills for disposal thus negatively affecting the environment. This of course leads, in turn, to the spread of diseases and increases the difficulties encountered for disposal.

Sources of Solid Waste a- Houses are the main source of the solid waste and are the main place, which necessitate proper waste disposal. b- Streets this is mainly dust and the amount of solid wastes depends on the population orientation to their health. Healthy communities have clean streets. c- Industries result in huge amount of solid waste mainly metals, containers and carton, this waste could be dangerous if it contains chemicals or poisonous material.

d- Hospitals, domestic wastes and medical wastes are thrown daily from hospitals. Hospital wastes should be managed carefully where it contains contaminated syringes, gloves, cotton and utensils of patients. This material could be a source of infection for the community if not managed properly.

Solid Waste disposal Extensive development of incinerators, improved collection trucks and procedures, solid wastes collection and disposal has assumed its place as protective measures for the public health. Hazards of Solid Wastes
1-Socio psychic: The population does not accept the sight of wastes. The heaps of waste could result in fire with all the hazards associated with this unsatisfactory event. 2-Economic: Disposal of the waste without proper utilization is an economic loss. Recycling is one of the ways were the material could be used again .

3-Health Hazards:
1- Fly& Rodent: Refuse is a good media for breading of flies and rodents. Both of them are harmful for human health.
2- Mechanical injuries: Where children are exposed to wounds and injuries if they handle the refuse un- properly. 3- Chemical pollution: Chemical hazards are common in factory waste. 4- Bacterial contamination: The chance of bacterial contamination is higher when hospital is present. Putrefaction of the organic material results in production of a great number of pathogens that could influence human.

Management of Solid wastes:

Management of solid wastes includes these items:
1- Collection 2-Transport 3- Disposal

a- Dumping

b- Incineration

c- Recycling

Pesticides & Toxic Substances Pollution

More than 350 metric tons of formulated pesticides (more than 100 pesticides) in addition to 800 metric tons of Methyl Bromide are used annually in Gaza Strip. Such heavy use of pesticides causes water pollution and soil degradation and contamination of the agricultural products which finally affect seriously the human and animals. It was found that 19 of these pesticides, that have been used, are internationally suspended, cancelled and banned pesticides, according to their mutogencity, carcinogencity , teratogencity and delayed neurtoxicity.

About 5800 cases of cancer have been registered in Gaza Strip (1990 - 1999). The distribution of cancer types among those patients are lung cancer, breast cancer, lymphoma and leukemia malignancy, head and neck, gastrointestinal malignancy, reproductive system, urinary system, soft tissue tumors, brain tumors and others . Consequently, the introduction and heavy use of pesticides and other toxic substances in the Gaza Strip environment is suspected to correlate with the growing incidence of cancer and other abnormalities in the nation. Precise determination of the effects of chronic exposure is, therefore, urgently needed. Finally, it is the responsibility of the civilized world to take the initiative towards regulating, production, exportation and importation of any suspected cytotoxicants.

Air Pollution Definition of Air Pollution: Concentration of foreign matter in the air which adversely affect the health and welfare of the people or their enjoyment. The most severe pollution is the chemical pollution. In Gaza Strip there is a large number of transportation means estimated at about 35,000 to 45,000 motor vehicles that constitute the major source of air pollution. Car exhausts release to the air large quantities of carbon monoxide, carbon dioxide, nitrogen oxides, hydrocarbons and lead that are considered very poisonous and some may be carcinogenic and may affect the respiratory and nervous system. Melting Lead and burning solid wastes are other major sources of air pollution in Gaza Strip.

Food Hygiene The primary objective of sanitary supervision over all places where food is prepared and served to the public is to prevent illness and possibly death from spoiled or contaminated foods.
The local health department is responsible for protecting the publics health against food contamination. Salmonella and staphylococci gastroenteritis germs are very prevalent and multiply rapidly in food and thus and food poisoning are the predominant infections transmitted by food. Other diseases transmitted by food include typhoid fever, amebic dysentery and bacillary dysentery.

FOOD BORNE DISEASES: I. Biological Agents 1. Food intoxication and bacterial infections: 1-1 Botulism: performed toxins produced by the growth of (Clostridium botulism) in food under anaerobic conditions cause Botulism. Symptoms develop in 2 hs to 8 days. 1-2 Staphylococcus food poisoning: The onset is 1-6 hours after ingestion 1-3 Amine poisoning: Cheese and alcoholic drinks or certain tranquilizers can result in such poisoning 1-4 Salmonellosis: Contamination of food by salmonella poses a significant public health problem

Other bacterial infections: Typhoid fever Shigellosis Streptococcal infections - Enterococci - Brucellosis - Dysenterys Viral Infections: -Infectious hepatitis -Others such as: poliomyelitis

- Hemolytic
- Cholera

Parasitic infections: - Amebiasis - Tenia - Tape worm diseases - Trichinosis from pork food - Giardiasis - Ascariasis

Chemicals and Radiation: Zinc, lead, Nicotinic acid, mercury acid, mercury, fluorine, lithium chromium, iodine, silicon, magnesium .. etc. pesticides are famous and known source of health hazards that endanger human life.

How can the environment affect our health? For better or worse, chemicals and other contaminants have become a part of everyday life. They exist in every aspect of our lives even before we are born. Hundreds of new chemicals are created every year. Exposure to large amounts of any substance can be harmful to ones health. However, some contaminants are more harmful, or toxic, than others.

There are many types of toxicity. When thinking about toxicity, researchers consider a chemicals ability to cause or promote cancer, or cause neurological problems (damage to the brain and nervous system), respiratory problems (like asthma), and reproductive problems (chemicals that may harm the developing fetus, or an individual's ability to conceive).

It is important to remember that some chemicals in small amounts can improve or protect ones health. Chlorine, which is used to purify drinking water, can be toxic in large quantities. In small quantities it protects us from cholera and other diseases.

Major environment-related killers in children under five years of age (WHO) Diarrhea kills an estimated 1.6 million children each year, caused mainly by unsafe water and poor sanitation. Indoor air pollution associated with the still-widespread use of biomass fuels kills nearly one million children annually, mostly as a result of acute respiratory infections. Malaria, which may be exacerbated as a result of poor water management and storage, inadequate housing, deforestation and loss of biodiversity, kills an estimated one million children under five annually, mostly in Africa.

Unintentional physical injuries, which may be related to household or community environmental hazards, kill nearly 300 000 children annually.

The solutions
In many cases, low-cost solutions for environment and health problems exist. For instance, simple filtration and disinfection of water at the household level dramatically improves the microbial quality of water, and reduces the risk of diarrhea disease at low cost. Education is also a key - mothers who receive the information they need to understand the environmental risks present in their homes and communities are better equipped to take appropriate action to reduce exposure.

Improved stoves reduce exposures to indoor air pollution. Better storage and safe use of chemicals at community level reduces exposures to toxic chemicals, especially among toddlers, who explore, touch and taste the products found at home. Personal protection from malaria through the use of insecticide-treated mosquito nets has a proven track record of saving lives, particularly children's.

What can we do to tackle the environmental risks to our children?

The Healthy Environments for Children Alliance (HECA) promotes a number of simple, low-cost, effective and sustainable measures to combat the environmental risks to our children.

Household water security Safe water storage at home and treatment of water in the home when its quality is in doubt - reduces water contamination and leads to proven health benefits.

Hygiene and sanitation Wash hands with soap before food preparation, before meals and after defecating significantly reduces the risk of diarrhea disease.

Follow the WHO Five Keys to Safer Food to reduce the risk of food borne disease: keep clean; separate raw and cooked; cook thoroughly; keep food at safe temperatures; and use safe water and raw materials.

Air pollution Good ventilation in the home, clean fuels and improved cooking stoves decrease indoor air pollution and the exacerbation and development of acute respiratory infections.

Disease vectors As children usually go to bed earlier than adults at the time mosquitoes become active, the use of insecticide-treated mosquito nets and the screening of windows, doors and eaves provide a very effective means of protecting them against malaria.

Chemical hazards Ensure safe storage, packaging, use and clear labeling of cleaners, fuels, solvents, pesticides and other chemicals used at home and in schools. Unintentional injuries Advocate for safer roads and organized traffic

Housing and Health Housing is a basic determinant of health, and many organizations, including the World Health Organization (WHO) and the American Public Health Association (APHA), have developed standards for healthy housing. The most important role of housing is to provide shelter from the elements. At its most basic level, housing needs to keep its inhabitants dry, warm (or cool), and safe.

For more info of what is possible, please refer to the HECA website:

Strategic objectives *Strengthen the capabilities and information exchange related to health, and environment (water, air, hazardous waste. vectors). * Protect portable water, indoor and outdoor air from pollution. * Protect form hazardous waste effects of environment & health

Protect the public from vectors and toxic materials.

Collaborate with the national local authorities in the creation of supportive environment for health.
Promote the environment of the non- governmental organization in planning and implementation of national plans and meeting national goals with special emphasis on health education.

Recommendations 1- Making environmental assessment by: a. Identifying the hazards present. b. Assess the effect of these hazards on the health of Individual, families and communities. c. Assess the risk factors. d. Diagnose and reasoning the environmental influence at health 2- Playing to control environmental hazards by primary, secondary, and tertiary prevention by increase health Education, treatment and rehabilitation.

Conclusion and Comments The environmental health is very important topic in relation to health and disease.

Clean air and water and effective waste management remains critical issues for 21st. century.
Increase scientific knowledge will decrease the hazards, which result from the environment.

So the use of preventive measures also decrease such hazards. Good health education and programs contribute in large benefit in the preventive measures. The degree of development of the country also assists this subject. Increase awareness among population also decreases the hazards and deceases the number of risks people.

Thank you