Chapter 6: Epidemiology and Environmental Factors

By identifying causes and risk factors for disease development, public health nurses can use evidence-based information to intervene early to reduce morbidity and mortality. For example, in 1950, epidemiologists Doll and Hill demonstrated a causal link between the development of lung cancer and smoking cigarettes. Their studies laid the foundation for public health initiatives to decrease rates of cigarette smoking. In 1965, 42 percent of adults in the United States smoked cigarettes, but by 2022 the rate had fallen to 19.8 percent (Centers for Disease Control and Prevention [CDC], 1999; CDC 2024).

Epidemiologic studies can identify how diseases are transmitted, enabling public health nurses to advocate for appropriate control programs. Diseases can be transmitted from person to person or from nonhuman sources, such as ticks or mosquitoes, to the human population. Well-designed epidemiologic studies have demonstrated how major communicable diseases are transmitted. For example, measures to ensure staff and client safety where tuberculosis may be present are based on the 1956 work of epidemiologists Riley and Wells (Thomas, 2020).

Determining the prevalence and extent of disease in a community is another function of epidemiology. Public health nurses can use this information to prepare for communicable disease outbreaks. For example, by using epidemiological statistical models, public health nurses can prepare adequate vaccine supplies and plan health services needed to respond to seasonal influenza outbreaks.

Public health nurses can also use evidence-based epidemiological information in health promotion education. For example, epidemiologists study whether screening improves survival for men with prostate cancer. Nurses can use the results of those epidemiological inquiries to assist them in educating at-risk communities. Epidemiological studies, such as studies seeking to discover whether high levels of radon in homes causes disease, can also inform nurses’ work to advocate for public policy at the local, state, and federal levels.

Core Functions

Public health nurses perform the core functions of assessment, policy development, and assurance to serve as a framework for addressing environmental health issues and promoting healthier communities.

Assessment: Conduct comprehensive assessments to identify environmental health hazards and concerns in the community. Perform data collection and analysis to identify sources of pollution, assess exposure risks, and evaluate the impact of the environment on health. Examples include performing environmental health assessments for individuals and communities.

Policy Development: Develop and advocate for policies and plans that promote a healthy environment. Collaborate with community partners and local governments to drive policies that positively impact the environment. Examples include advocating for clean water and policies that consider climate change.

Assurance: Monitor and evaluate the implementation and effectiveness of environmental policies and programs. Ensure action when hazards are identified or regulations violated. Examples include educating the community about contaminated water, ensuring that a safe alternative is provided, and advocating for infrastructure updates.

Prevention

Nurses have a pivotal role in safeguarding environmental health by implementing prevention interventions across the continuum of health care. It is critical to consider the upstream approach mentioned earlier in the chapter when developing interventions. For example, consider the community’s potential hazards at each level of prevention. At the primary prevention level, nurses focus on promoting awareness, education, and advocacy to prevent environmental health risks before they occur. Secondary prevention encompasses early detection and intervention to mitigate risk and impact. Tertiary prevention focuses on minimizing the impact of already existing environmental health concerns by enhancing patient outcomes and facilitating recovery.

Primary Interventions:

• Provide education about the importance of environmental health and strategies for reducing risk and improving outcomes.
• Engage and empower communities to adopt healthy practices and policies that contribute to a cleaner environment, such as proper waste management and updating infrastructure.
• Advocate for policies to reduce air pollution and hazardous waste in the community.
• Advocate for policies to promote environmental protection, such as green building practices.

Secondary Interventions:

• Conduct regular environmental health assessments to identify individuals, groups, and communities at risk.
• Establish surveillance systems based on the community’s potential hazards to monitor environmental health indicators, detect signs of issues, and intervene promptly.
• Screen for home hazards such as lead and mold.

Tertiary Interventions:

• Provide care and interventions to individuals affected by severe health consequences of environmental hazards.
• Develop emergency response plans specific to the community’s hazards and needs to manage environmental disasters and extreme weather events.
• Engage in research to better understand the health impacts of various environmental hazards among clients.

6.5 Climate Change, Justice, and Advocacy

Nurses have distinctive strengths for addressing climate change. As the most trusted professionals in the United States, nurses are positioned to be powerful messengers for climate-related information. Nurses are trained communicators and often serve as the first point of contact for health and health care, providing an opportunity to incorporate environmental health assessments, climate change education, and interventions. Nurses working in the community are closely connected to vulnerable populations and can address issues of climate equity and justice (Butterfield et al., 2021). Becoming involved in a professional nursing organization promoting climate justice provides nurses with resources and a platform from which to make transformative changes (Alliance of Nurses for Healthy Environments, 2023).

Primary Interventions:

• Educate the community about the health risks of climate change (Lokmic-Tomkins et al., 2023).
• Encourage community engagement with climate change mitigation efforts, such as community gardens, recycling programs, and energy-efficient practices (Salvador Costa et al., 2023).
• Provide information on adaptive behaviors to increase resilience, such as staying hydrated during heat waves.
• Collaborate with local authorities to advocate for climate-resilient infrastructure such as renewable energy initiatives and developing clean, efficient, and adequate public transportation (Salvador Costa et al., 2023).
• Ensure that communities are prepared for extreme weather events by promoting the development of cooling centers, evacuation routes, and emergency shelters.
• Facilitate connections between community members and community partners to increase social cohesion and resilience.
• Integrate climate-focused education and patient-centered conversations into nursing practice (Lokmic‐Tomkins et al., 2023).

Secondary Interventions:

• Conduct screenings to identify vulnerable populations within the community and develop strategies to protect their health during climate-related events.
• Ensure that community members receive timely information and advice on staying safe, such as staying indoors during extreme heat or using masks during poor air quality periods.
• Establish or ensure surveillance systems to monitor health outcomes associated with climate change (Lokmic-Tomkins et al., 2023).

Tertiary Interventions:

• Establish plans for providing health care services in the aftermath of climate-related events.
• Ensure that health care facilities are equipped to manage crises triggered by extreme weather events and climate-related disasters (Salvador Costa et al., 2023).
• Train health care professionals to recognize and address health issues related to or exacerbated by climate change.
• Evaluate the effectiveness of interventions and policies aimed at mitigating and adapting to climate change health risks and recommend improvements based on findings.
• Work with communities to adapt to identified climate change risks and needs (Dion et al., 2022).
• Provide mental health support and referrals for those affected by the psychological stressors of climate-related events.

Reference

Alliance of Nurses for Healthy Environments [ANHE]. (2023). Climate justice agenda for nursing. https://envirn.org/climate-justice-agenda-for-nursing/

Butterfield, P. (2021, June 14). Nursing’s pivotal role in global climate action. BMJ, 373(1049). doi:10.1136/bmj.n1049

Celentano, D. D., & Szklo, M. (2019). Gordis epidemiology (6th ed.). Elsevier Health Sciences.

Centers for Disease Control and Prevention. (1999). Achievements in public health, 1900–1999: Tobacco use—United States, 1900–1999. MMWR Weekly, 48(43), 986–993. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4843a2.htm

Centers for Disease Control and Prevention. (2024). Current Cigarette Smoking Among Adults in the United States. https://www.cdc.gov/tobacco/php/data-statistics/adult-data-cigarettes/?CDC_AAref_Val=https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm

Dion, K. W., Oerther, D. B., & Lavin, R. (2022). Promoting climate change resilience. Nursing Economic$, 40(3), 139–145.

Frérot, M., Lefebvre, A., Aho, S., Callier, P., Astruc, K., & Glélé, S. A. (2018). What is epidemiology? Changing definitions of epidemiology 1978–2017. PLoS ONE, 13(12), 1–27. https://doi.org/10.1371/journal.pone.0208442

Lilienfeld, E., Nicholas, P. K., Breakey, S., & Corless, I. B. (2018). Addressing climate change through a nursing lens within the framework of the United Nations Sustainable Development Goals. Nursing Outlook, 66(5), 482-494. https://doi.org/10.1016/j.outlook.2018.06.010

Lokmic-Tomkins, Z., Nayna Schwerdtle, P., & Armstrong, F. (2023). Engaging with our responsibility to protect health from climate change. Journal of Advanced Nursing, 79(6). https://doi.org/10.1111/jan.15508

McCauley, L., & Hayes, R. (2021). From Florence to fossil fuels: Nursing has always been about environmental health. Nursing Outlook, 69(5), 720–731. https://doi.org/10.1016/j.outlook.2021.06.007

Salvador Costa, M. J., Melo, P., Azeiteiro, U., Carvalho, S., & Ryan, R. (2023). Nursing interventions to reduce health risks from climate change impact in urban areas: A scoping review protocol. Nursing Reports, 13, 496–505. https://doi.org/https://doi.org/10.3390/nursrep13010045

Thomas, K. K. (2020). The experiment that proved airborne transmission. Johns Hopkins Bloomberg School of Public Health. https://publichealth.jhu.edu/2020/the-experiment-that-proved-airborne-disease-transmission