Applied epidemiology and environmental health: emerging controversies

Getting strategic about the environment and health

Historically, the physical environment has been a target for public health policy across the globe. This remains the case in developing countries where the enduring infectious and toxic challenge posed by the environment is tangible and its health impact is manifest. However, in Western societies, the relevance of the environment to health has become obscured. Even when this is not the case, the perspective is usually narrow, centering on specific toxic, infectious or allergenic agents in particular environmental compartments. It is rare for importance to be given to a health-determining role for the environment acting through broader psychosocial mechanisms. The result is that environmental manipulation is seen as a cornerstone of the public health response for comparatively few health concerns. This paper considers how public health policies and action on the physical environment may be pursued more optimally. The need for a more strategic approach, which employs a new conceptual model that recognizes the complexity and contextual issues affecting the relationship between the environment and health but retains sufficient flexibility and simplicity to have practical application, is identified. Building on recent work, a model is proposed and pointers are given for its use in a practical context.

Long-term impact of worker notification: qualitative assessment of a community-based notification and screening program in Augusta, Georgia

BACKGROUND

Evaluation of high-risk worker notification programs often focuses on their immediate effectiveness in communicating information to individual workers. This approach leaves unexamined some important social processes that can influence worker notification's impact and public health consequences over time.

METHODS

To explore long-term effects, ethnographic methods were used for qualitative assessment of a community-based program carried out by the National Institute for Occupational Safety and Health (NIOSH) in Augusta, Georgia, during the early 1980s. More than a decade after the original NIOSH intervention, lengthy taped interviews were conducted with 70 members of the notified cohort (chemical workers exposed to beta-naphthylamine (BNA)) and 32 members of their families.

RESULTS

The notified workers expressed extremely positive feelings about having received the risk information. However, for non-obvious and unanticipated reasons, most had failed to implement the notification's primary health advice (annual screening for bladder cancer). Both the workers and their family members reported a number of ongoing concerns related to the program.

CONCLUSIONS

The study findings suggest four strategies, all relatively low in cost, that are likely to increase the long-term public health benefits of worker notifications that rely on individually mailed written materials: (1) in designing worker notifications, take into account the information (accurate or not) that the workers already have, and determine what kind of information they most want and need; (2) define the notification audience broadly to include not only the study cohort but also family members and/or other similarly exposed workers; (3) when notifications recommend secondary disease prevention measures over long time periods, follow up the notification health advice with periodic reminders; (4) inform a wide range of community organizations and service providers (non-medical as well as medical) about the notification, and encourage them to provide appropriate support to the notified workers and their families.

The social consequences of occupational injuries and illnesses

BACKGROUND

Most outcome studies of occupational injuries and illnesses have tended to focus on direct economic costs and duration of work disability. Rarely have the broader social consequences of work-related disorders or their impacts on injured workers' families, coworkers, and community been investigated. This paper examines a wide range of social consequences including workers' psychological and behavioral responses, vocational function, and family and community relationships.

METHODS

Literature review and development of conceptual framework.

RESULTS

Complex and multifactorial relationships are described whereby occupational injuries and illnesses produce a variety of social consequences involving filing and administration of workers' compensation insurance claims, medical care experiences, domestic function and activities of daily living, psychological and behavioral responses, stress, vocational function, rehabilitation and return to work, and equity and social justice.

CONCLUSION

A research agenda is proposed for guiding future investigations in this field.

Applied epidemiology for the 21st Century

BACKGROUND

Critics argue that the modern epidemiologist seems more concerned with intricately modelling complex relationships among risk factors than understanding their origins and their implications for public health. Indeed, some contend that epidemiology has reached its limits as a discipline. To address such concerns, alternatives have been proposed that integrate biological, analytical, and social approaches to epidemiological practice and training.

METHODS

The published literature was reviewed to examine critical issues in current epidemiological practice and training. In addition, we reviewed records of training programmes in applied epidemiology established in 20 countries.

RESULTS

We describe an existing approach to preparing epidemiologists for the emerging challenges of public health in which epidemiological research and practice are applied toward the end of improving public health and health care. Training in applied epidemiology is based on a philosophy of 'learning while doing'. Under the supervision of an experienced epidemiologist, trainees conduct field investigations, analyse large data bases, evaluate surveillance systems, publish and present scientific research, and respond to public enquiries. More than 3000 people have received intensive formal training over the past 50 years in programmes in more than 20 countries; most graduates continued to use the tools of applied epidemiology in their work.

CONCLUSION

Training in applied epidemiology anchors the discipline in population-based, relevant public health practice.