Section 18. PACE EH: Protocol for Assessing Community Excellence in Environmental Health

Learn about the protocol for assessing community excellence in environmental health (PACE EH) process, which provides active and meaningful community involvement in the development of environmental public health policies and priorities.

 

• What is PACE EH?

• Why use PACE EH?

• Who should be involved in using PACE EH?

• When should you use PACE EH?

• How do you use PACE EH?

 

 

At one point or another, nearly every person whose work centers on serving community needs is introduced to a small, but insightful, morality play known as the “tragedy of the commons.” The allegory relates the consequences of uninformed individual consumption of community-held resources. In the tale, a group of herdsmen bring their livestock to a parcel of communally held land at different times throughout the year. Because each herder is selfishly concerned only about the welfare of his livestock, none takes responsibility for the well-being of the land itself. Overgrazing results in the eventual death of all the herders’ livestock. Had the herdsmen worked together and jointly accepted the responsibility for the upkeep of the land, all would have prospered…

The true “tragedy of the commons” has always been how easily such hardship could have, and should have, been avoided. Contemporary environmental health risks, mirroring the subtle yet predictable loss of land in the fable, have the potential to grow destructive through inattention and inaction. Application of the PACE EH methodology is a step towards ensuring that the “tragedy of the commons” remains an instructive fable rather than a glimpse of the future within the field of environmental health.

From PACE EH in Practice: A Compendium of Ten Pilot Communities. NACCHO, 2002.

Community health is more than simple freedom from disease for most individuals in the community. It encompasses the community’s involvement in the promotion of healthy behavior and conditions, in the prevention of disease and injury, and in the provision of health care for all. The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

Given this wide-ranging view of health, communities can’t ignore the environments in which their residents live, work, and play. These environments must of course include the natural world, with its geographic features, its climate, and its plants and animals. But they also include the built environment – buildings, roads, and all the other human-created aspects of the modern world that surround us – and the social, political, and economic environments that we, as communities and societies, construct for ourselves.

When you consider health from an environmental perspective, it becomes clear that the issues raised go far beyond the standard concerns of most health providers, and can extend into such areas as community planning, environmental law, ecology, human rights, equity, economic development, construction techniques, climate change…the list can go on and on. Just about any community has a number of environmental concerns of various kinds. How can a community, and/or its health department or public health agency, decide what’s most important to tackle, and what can actually be accomplished?

In this section, we’ll profile the PACE EH process, which can help communities build partnerships to make good decisions about environmental health issues. We’ll explain the process and how it works, when and by whom it can be used, and how a community can use it to plan and implement an environmental health strategy.

What is PACE EH?

PACE EH (Protocol for Assessing Community Excellence in Environmental Health) is a process for assessing and analyzing the environmental health of communities and for creating plans to address threats and create improvements. The process and the partnerships it creates in the community then become the basis for regular reassessment of and attention to environmental health.

PACE EH was developed in partnership by the National Association of City and County Health Officials (NACCHO) and the National Center for Environmental Health (NCEH) of the U.S. Centers for Disease Control (CDC), along with representatives of state, local, and federal environmental and health agencies and institutions. Before the PACE EH Guidebook was written (available free as a pdf file or for a price as a print document), ten communities piloted the process, and their experience was used to inform its current version. Much of the material in this section comes, either directly or indirectly, from the guidebook.

While the Guidebook provides a variety of tools and suggestions – many of them included in the Tools for this section – for making the process go smoothly, it emphasizes that these are intended as just those: tools and suggestions. They are meant to be used if they’re helpful, but to be changed or tossed aside in favor of more locally appropriate means when that’s necessary.

PACE EH is based on four underlying principles:

• A community-based environmental health assessment supports the core functions of public health.

The Ten Essential Public Health Services, adopted as part of a consensus statement of public health services and priorities by U.S. public health leaders and agencies in 1994:

1. Monitor health status to identify community health problems.
2. Diagnose and investigate health problems and health hazards in the community.
3. Inform, educate, and empower people about health issues.
4. Mobilize community partnerships to identify and solve health problems.
5. Develop policies and plans that support individual and community health efforts.
6. Enforce laws and regulations that protect health and ensure safety.
7. Link people to needed personal health services and ensure the provision of health care when otherwise unavailable.
8. Assure a competent public health and personal healthcare workforce.
9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
10. Research for new insights and innovative solutions to health problems.

• Strengthening leadership abilities in the field of environmental health will make local health officials more effective in ensuring the health of the community.
• Community collaboration is the cornerstone of a useful environmental health assessment process and of effective community planning.
• Principles of environmental justice, whether explicit or implicit, underlie the practice of sound local public health and environmental health.

PACE EH is designed to help communities explore and find the answers to a number of questions about their own environmental health:

• What are the connections between the environment — where people live, work, learn, and play — and human health and wellbeing?
• Are certain groups in the community currently experiencing, or likely to experience, an increased risk or disproportionate share of adverse health effects from environmental hazards?
• What can be done to protect human health and the environment?
• How appropriate and effective are current environmental health protection measures in the community?
• What are some of the key environmental resources in communities that should be preserved or protected?

The process intentionally says little about how to address specific environmental health issues, leaving that to each community. This is in keeping with a basic principle underlying PACE EH: that community members know their community best, and must be involved in the assessment of environmental health issues and in planning the actions designed to address them. The PACE EH process is meant to be inclusive and participatory from the beginning, involving both individuals from the community and organizations and agencies from all sectors.

The assumption is that the lead in assembling a coordinating body will be taken by the local or state public health department or board. While that certainly makes sense, there may be occasions where the process is started by concerned citizens, or by another agency. The goal in either case is to form a partnership among a wide range of individuals (including individuals often left out of such discussions: low-income and minority residents, those who don’t speak English, youth), organizations, and institutions.

PACE EH was developed for use in the U.S. by an American government agency and an American NGO. There is no reason, however, why the process can’t be used, with appropriate adaptation where necessary, in other societies. Environmental health is a concern everywhere, and this is a process that doesn’t specifically rely on American resources, laws, or values. In some places, people may need more education and discussion about the meaning of environmental health than in others, but that doesn’t mean that they can’t understand or participate fully in the process.

PACE EH is constructed around 13 tasks

1. Determine Community Capacity to Undertake the Assessment
2. Define and Characterize the Community
3. Assemble Community Environmental Health Assessment Team
4. Define the Goals of the Assessment
5. Generate the Environmental Health Issue List
6. Analyze Issues with a Systems Framework
7. Develop Appropriate Community Environmental Health Indicators
8. Select Standards
9. Create Environmental Health Issue Profiles
10. Rank the Environmental Health Issues
11. Set Priorities for Action
12. Develop an Action Plan
13. Evaluate Progress and Plan for the Future

We’ll discuss each of these tasks in more detail in the “how-to” part of this section.

While these tasks are laid out as a sequence, the guidebook emphasizes that each community is different, and that, in some cases, a community may work on more than one task at a time, or switch the order of some. Flexibility, which allows PACE EH to be adapted to the needs and concerns of each community that uses it, is an important element of the protocol.

Why use PACE EH?

• PACE EH is a participatory process. It seeks to involve all stakeholders in the community as much as possible. Participation of this kind is not only fair to those who will be affected by decisions the Community Environmental Health Assessment (CEHA) team makes, but it also has two other great advantages: First, it draws on the experience and knowledge of a broad range of community members, so that the final plan is likely to address the real needs of community members in a way that reflects their concerns. Second, it encourages ownership of the plan, because it was created by a group that represented the whole community and used residents’ ideas and concerns in the process. If community members feel ownership, they’ll support the plan and work to make it successful.
• The process brings together numerous people and organizations from various sectors, many of whom may not usually have contact. This lays the foundation for future collaboration in many areas, and makes coordination of services and efforts much easier.
• PACE EH takes a community perspective on health. The WHO, the CDC, and others have long realized that developing a healthy community depends on looking at the community as a whole. The availability and quality of medical care is only one of many factors that contribute to that development. The PACE EH perspective deals with as many of those factors as possible.

As early as 1985, WHO, in what has come to be called the Ottawa Charter, stated that a truly healthy community provides residents with peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity.

• PACE EH is flexible. The process not only allows, but requires the community to set its own agenda, decide what it wants to work on, and plan how to reach its goals. The assumption of the process is that communities are different and that each needs to consider its unique character and needs in order to make real and lasting changes.
• The process helps empower communities to identify and use their own resources. It puts communities in control by helping them to understand how many assets they have and can use to address environmental health and other issues. Furthermore, by bringing together so many organizations, individuals, agencies, and institutions, it creates a resource – an interconnected and collaborative network – that can be activated again and again to maintain changes and address a variety of other community concerns as well.
• PACE EH looks at the environment in an inclusive way. It allows the community to define the environment as broadly as it needs to in order to get at the real context of community health issues. Thus, environmental health can include such issues as violence and drugs, which can create health problems directly, or the lack of transportation, which can hinder social connectedness, a proven health benefit.
• PACE EH raises the profile of the environment as the foundation and context of community health. Those involved in the PACE EH process, especially those whose experience has been in narrowly defined areas, can come to view both the term “environment” and the community environment itself in a different way. By the same token, the activities spawned by PACE EH can help to educate the community about the importance of the environment to health and about the concept of environmental health.
• Through the CEHA team and associated work groups, PACE EH builds leadership and connections for other initiatives and issues, health-related or not.
• The process is structured to keep all participants focused on the community and its concerns, rather than their own. It specifically provides suggestions to keep one-issue proponents from pushing their agenda at the expense of issues that are equally or more important to the community.
• PACE EH examines environmental issues in a systems framework. By looking at all the factors involved in an issue and analyzing how they interact, the CEHA team is more likely to get at real causes and effectively deal with problems or make improvements. The systems perspective helps communities find and target the pressure points of the system – the places where the whole system can be changed, sometimes by a relatively simple action – rather than simply treating the symptoms of a problem.
• Because of its structure, the PACE EH process is likely to have a real impact on community health. With its participatory nature, its whole-community and systems perspectives, and its view of the environment as the context of a healthy community, PACE EH is more likely than a more narrowly-focused process to lead to significant improvements in community environmental health.

Who should be involved in PACE EH?

An environmental health assessment is meant to benefit everyone in the community, however community is defined. Depending on the circumstances, the PACE EH process may be aimed at the whole community, at a particular area or neighborhood, at a particular population…there are many possibilities. Whatever the case, all stakeholders should be part of the process in some way – represented on the CEHA team, among workgroups or subcommittees, or consulted as part of data gathering and choosing issues.

Stakeholders include individuals who are or may be directly or indirectly affected by environmental health issues, those who provide services to or depend upon those people, those who might be asked to carry out actions to address environmental issues, concerned community activists and advocates, and policy makers and other officials who have the power to make changes in laws and regulations that can have an effect – positive or negative – on environmental health. Some examples:

People affected by environmental health issues

• Vulnerable populations, particularly those who might be subject to environmental discrimination (tenants of low-income public housing that has been built in an industrial neighborhood, for example)
• People with respiratory diseases or other environmentally-influenced health conditions
• Workers in dangerous or unhealthy jobs

In reality, everyone is affected by environmental health issues. Some populations, however, generally because of poverty or discrimination, have less control over their exposure to hazards and fewer opportunities for health-promoting activities and behaviors. Low-income and minority neighborhoods are often the last to receive services, and both physical and social environmental issues in those neighborhoods may be ignored. People with asthma and other respiratory diseases are at the mercy of air quality, which may be bad everywhere, not just in their immediate area. Workers in some industries or facilities may be forced to endure unhealthy or dangerous conditions for fear of losing their jobs. These and other vulnerable groups may gain a voice and some control over their situations by participating in a PACE EH process.

People indirectly affected by environmental health issues

• Landlords who might be responsible for removing environmental hazards, such as lead paint, from buildings or land
• Business owners who may have to change their use of products or methods

Individuals and organizations that provide services to affected populations

• Health professionals and institutions
• Human service organizations
• Educators and schools
• Public services – police, fire, EMS

Government

• Federal/state/local environmental agencies and officials, including Department of Public Works and similar functions
• Public health agencies – state/federal/county DPH, local boards of health

Advocacy and community groups

• Environmental organizations
• Community activists
• Faith communities

Others with a vested interest

• Business and industry
• Labor
• People with expertise in relevant areas – scientists, university professors, researchers, students, professionals

This is not a complete list, and the implication is not that all of these groups necessarily have to be involved in any given PACE EH process. It depends on the community, on the circumstances, on the issues, and on the population affected. An advantage of PACE EH is that it allows each community to determine who needs to be involved and how.

When should you use PACE EH?

PACE EH is a model that can and should be used at any time. There are, however, some specific situations when it would be particularly appropriate.

• When the community is experiencing rapid growth. Rapid development can have consequences to air and water quality, wildlife habitat, land use, food production, open space, housing cost and availability, the local economy, and many other areas that can affect environmental health. A PACE EH process can help to lessen the impact of fast growth and can lead to the encouragement of healthier building and land use.
• When a new commercial or residential development is being proposed. PACE EH can help the community understand current issues, assess how they will be affected by the proposed development, and help the developer find ways to make the project environmentally friendly.
• When a new industry is moving in. Most industry, even if it’s low-impact, carries environmental consequences. It may create pressure on housing or services by bringing more people into the community, or build in well-used open space. Agriculture can be responsible for major amounts of water pollution, caused by fertilizer runoff from fields and from manure piles and tanks. PACE EH can aid the community in understanding and anticipating possible impacts on environmental health and in planning to counteract them.
• When changes are proposed that will affect the natural environment. The new developments or industry mentioned above may fall into this category, but so do road building and road improvement, lumber operations, mining, dams, and even “green” installations, such as wind farms and solar power arrays.
• When there’s an upsurge in what might be environmentally-caused illness, or when community health seems to be deteriorating. Environmental factors involved in health changes might include the ability of the area to attract medical professionals, economic conditions, pollution, the introduction of new diseases or new vectors, changes in diet, or a host of other factors. PACE EH can help to identify and prioritize causes and lead to action to improve community health.

Vectors are living creatures that spread disease. Mosquitoes are a vector for malaria, for instance, because they can be infected with the parasite that actually causes the disease.

How do you use PACE EH?

Most of this part of the section comes from the PACE EH Guidebook for Local Health Officials, first published in 2000 and revised in 2008. The Guidebook is available as a pdf file (free) or in print (not free) from the NACCHO website.

The 13 tasks that make up the substance of PACE EH lay out the process. We’ll look at each of them in turn, but first, there are two pre-process considerations: initiating the process and dealing with long-standing distrust or bad feeling.

Initiating the process

One of the core assumptions behind PACE EH, as we’ve discussed, is that the local or state public health agency must be the convener, and that may usually be true. There may, however, be circumstances where the public health agency is unable or unwilling to take the lead. The agency may be hampered by lack of funding, over-commitment, or under-staffing. Public health officials may be unwilling to give up control to the community, may not see environmental health as a priority, or may feel that an environmental health assessment would be too controversial, and might hurt other necessary programs. Public health policy and actions are also sometimes driven by political or economic pressure, which may push against an assessment.

In any of these circumstances, another convener may have to step forward. This might be a community-based organization or coalition, a community health provider (a free clinic, an independent hospital), an environmental group, or even a determined and knowledgeable individual, to name just a few of many possibilities. The only requirements are a commitment to environmental health and the underlying philosophy of PACE EH and the ability to bring together all the necessary stakeholders to participate in the process…which leads us to the second pre-process issue.

Dealing with long-standing distrust or bad feeling

What if there is distrust of the logical convener – the public health agency – or general distrust or bad feeling among some of the organizations and/or individuals who need to be involved? When this is the case, a community PACE EH process is not likely to succeed without a fair amount of groundwork. Relationships need to be established or mended, trust needs to be built. It is far more difficult to convince organizations or individuals that have had a bad history to work together than it is to convince those who don’t know one another at all.

Once a convener has begun the process and has managed, if necessary, to create a climate where collaboration among the stakeholders is possible, work on the 13 tasks can begin.

A question: what should the first task be? The guidebook lists it as determining community capacity, but it seems that it could be instead assembling an inclusive planning team or at least an oversight body for the environmental health assessment process. It would no doubt be more efficient to have the public health agency conduct the first two tasks before starting to assemble a team, but community ownership and trust might be much greater, and therefore make the rest of the process easier, if the community were clearly involved from the onset. That said, we’ll examine the tasks in the order in which they appear in the Guidebook.

Task 1: Determine community capacity to undertake the assessment

The first order of business is to determine what resources are needed in order to carry out the assessment, and whether the community has and/or can reasonably expect to assemble those resources.

Specify the resources, skills, and capacities needed for assessment. The essential resources for any community undertaking are generally money, people, time, and technical skills of various kinds. The amount of funding, the number of people and the kinds of technical skills will vary with the needs of each community. Time refers both to the total amount of time an assessment will take, which may be as much as a year or two; and the amount of time the organizations and individuals involved can give to developing and implementing a plan to improve environmental health.

According to the guidebook, the essential skills and capacities needed include:

• community mobilization
• qualitative data management
• coalition building
• leadership
• communication
• public outreach
• strategic planning
• time management/project management
• survey methodology
• data collection and analysis
• group process
• epidemiology
• access to technical support
• public relations/marketing
• political savvy

Specify the available resources, skills, and capacities. The convener or lead agency, whether the public health agency or another, must have the internal capacity to coordinate and manage the assessment, a willingness to give up control, and the external relationships with other organizations and the community that give it the ability to assemble an inclusive planning group. In addition, community resources should be identified. Buildings, organizations and institutions, people, facilities, media – there are probably assets in all of these and other areas in practically any community. Finding and using them, through asset mapping or other means, is vital.

Review possibilities for collaboration. The next question to ask is whether the lead agency has or can develop the relationships necessary for a true community collaboration. Efforts should be made to understand and address rifts among organizations or within the community, so that a collaborative effort has a good chance of success.

Determine ability to carry out the assessment. At this point, it should be apparent whether or not there exist the local resources to carry out the PACE EH process. If not, engaging in the process can perhaps help to increase and strengthen them, although, in this circumstance, the effort will probably take longer.

Task 2: Define and characterize the community

The next step is to take a close look at the community you’ll be assessing.

Define the community. Community has many meanings. It most often refers to a geographic area with specific boundaries – a city, a town, a neighborhood, a distinct rural area – but it can also refer to any group of people with something important and identifiable in common – culture, race, ethnicity, class, language, occupation, or even ecosystem or watershed. Whom will the PACE EH assessment serve? You have to decide exactly where the borders – geographic, social, economic, and/or political – of your community are, and what and whom they include.

Describe the community’s characteristics, composition, organization and leadership. A community description includes demographics (age, gender, race, etc.), health data, socio-economic statistics, physical characteristics (built and natural), educational status, language, culture, religion, major employers, and the like. Other key information concerns the history and current state of the community, its formal and informal leaders, its conflicts, and who influences its decision-making and how.

Refine the definition of the community as needed. As conditions change, and as time goes on, you should revisit your definition of community and make sure that it still represents the reality and doesn't define the effort either too broadly or too narrowly.

Task 3: Assemble a Community-based Environmental Health Assessment Team

The information you’ve gathered in the first two tasks should tell you who needs to be part of the CEHA Team.

Clarify expectations of team members. The roles, responsibilities, and rights of team members should be carefully framed. Clarity will help individuals and organizations decide whether to join the team, and will eliminate misunderstandings later.

Identify and invite individuals to help design and carry out the assessment. The team should represent various sectors. (See the “Who…?” part of this section above for examples of individuals and groups that might be included.) Its composition should also reflect the diversity and composition of the community, including, to the extent possible, youth; seniors; women; members of racial, ethnic, cultural, and language minorities; people from all socio-economic levels; etc.

Determine a governing structure, decision-making structure, and ground rules. How will the team operate? The best answer to this question is usually developed by the team itself at the very beginning of the process. Whether there will be a chair and who it will be, how the work will be done and who will do it, meeting schedules and agenda-setting, whether there will be subcommittees and how they’ll be filled and structured, where resources will come from and who will be responsible for pursuing them, the ground rules for the work of the team (e.g., participate actively, deal with ideas rather than people, use conflict constructively, listen actively, respect others’ opinions, etc.) – all of these and more are questions that should be addressed at the very beginning by the team, so that work can proceed in an atmosphere of clear expectations and trust.

Task 4: Define the goals, objectives, and scope of the assessment

Involving the community in this task will help cement support for the process.

Establish goals and objectives for the assessment. Goals describe what you hope to ultimately accomplish. Objectives describe what you have to do to achieve your goals, and may often include a deadline.

Describe the vision that will guide the process. To get community ownership, the community should be engaged in helping to define the vision for the process. That may mean being kept up to date while a representative group drafts a vision statement, or it may mean that the community is directly involved (through public meetings, surveys, or other means) in creating the vision or in refining a statement that the CEHA team presents to them.

Describe the scope of issues to be addressed by the assessment. This is the process of deciding what will and won’t be included in “environmental health” for your community. The Guidebook provides a useful diagram to help the group think about this issue:

 

The size and position of the circle should vary – often greatly – from community to community, depending on how each sees its environmental problems and needs. A rural community may be very concerned with preserving open space and the ecology of the community, while an urban community might be more concerned with specific point sources of pollution or reducing the triggers for asthma. The scope of issues depends on the community’s circumstances, the resources available, and the way the community chooses to define environmental health.

Define key terms. “Health,” “environment,” and “environmental health” may mean different things to different communities. It’s necessary that CEHA team members (and the community) agree on the definitions of these and other relevant terms, not only to mark out the scope of the environmental health assessment, but to proceed in the future to address environmental health needs. The definitions may change as the community and its priorities change, and should probably be revisited at least annually.

Task 5: Generate a list of environmental health issues

With this task, the work starts to become more specific: what is the community actually concerned with, and what will the effort work on?

Evaluate and select data-gathering method(s). In the words of the Guidebook, “Community assessments are simultaneously research projects and efforts to engage the community around environmental health issues. Therefore, the process of gathering information on the community’s concerns needs to do more than build on the existing base of knowledge and gather additional community-specific information. It should also foster the community’s understanding of the project and provide opportunities for community engagement.”

The logical extension of this statement is the creation of a participatory action research project, where some or most of the data is not only supplied, but gathered, by members of the community. There are a number of advantages to this approach, including community participation and ownership; the greater openness of people when approached by those whom they know or can identify with; and the knowledge of community members about the reliability of informants, the community’s history, and the issues that affect the community most deeply.

There are a number of ways to gather data: written or oral surveys, formal or informal individual and/or group interviews, community forums, focus groups, and even direct observation. Data gathering can be structured and formal, or more informal, can focus on quantitative or qualitative methods, or can combine different techniques. What you choose will depend on your resources (formal randomized surveys are usually conducted by consultants, and can be very expensive), the nature of your community, and the preferences of the CEHA team.

Collect data on community concerns. Use the methods and researchers you’ve chosen to gather data about what the community sees as environmental health issues.

Collect data on community knowledge, attitudes, behaviors, and perceptions. To understand community concerns, it’s important to also understand what community members know, don’t know, and would like to know about environmental health conditions; their attitudes about environmental health and health risks; behaviors they engage in that can put them or others at risk for or protect them from environmental health threats; and how they perceive the risk posed by various environmental health issues.

Risk perception is often based on factors that have little to do with actual risk. People often respond to sensational media reports or to spectacular events more strongly than to day-to-day occurrences. Thus, citizens may feel that they are at increased risk of being crime victims, even when crime is dramatically decreasing, because of the way violent crime is reported, or because of an acquaintance’s experiences or fears.

Create a manageable list of issues. Any community might have a host of potential environmental health issues. In order to whittle the list down to a reasonable number, the Guidebook suggests asking some pointed questions of each possibility:

• Does the issue fall within the intended scope of the assessment?
• Does the issue represent a relationship between the environment and human health?
• Is it a local concern?
• Was this an issue identified by a significant majority of the public?
• Can other information from the community support the inclusion of this issue?

Task 6: Analyze the Issues with a Systems Framework.

Systems theory assumes that no issue exists in a vacuum. Each is both caused and structured by a much larger system that includes the context – physical, geographic, social, etc. – in which it exists and the factors and conditions – climate, behaviors and policies that increase or decrease its effects, people who are harmed and benefited by it, community attitudes about it, the science that makes it possible or that can change it, to name just a few – that contribute to it. “In the framework, environmental health status is described by linking contributing factors – public policy decisions and personal behaviors – with exposure factors that describe how and where affected populations are exposed to environmental agents/conditions and the public health protection factors that are implemented by individuals or communities and reflect the collective capacity to address environmental health issues” (Guidebook, p.29):

Name of Issue

 

Understand the framework. In order to use this framework effectively, it’s important to understand what the elements of it refer to, and how they fit together and affect one another. From the Guidebook:

• Contributing factors are the activities, practices, or behaviors of society or individuals that affect environmental conditions or that place individuals at potential health risk.
• Environmental agents and conditions are chemicals, biologic agents, radiation, and other physical conditions in the built or natural environment that may be connected to human health, environmental quality, or quality of life.
• Exposure factors describe how and where people are exposed to potentially hazardous environmental agents or conditions. These include the place of exposure, activities that can lead to exposure, and route of exposure.
• Affected populations are groups who may be at risk of exposure. They are any segment of the community that is likely to experience the health state of interest or to be affected by the environmental condition.
• Public health protection factors are the personal protection factors (individual behaviors, such as wearing protective gear and getting immunizations) and community protection factors (community actions or systems – pollution control regulations, mosquito control) that can either modify or prevent an environmental health concern, or maintain an area of environmental health quality in the community.
• Environmental health status can be described in terms of an acute or chronic health condition or quality of life concern that is known or suspected to be environmentally related. Issues may reflect existing concerns or potential future concerns if preventive measures are not maintained or initiated.

Identify the connections among health status, affected populations, exposure factors, environmental agents/conditions, contributing factors and behaviors, and public health protection factors for selected environmental health issues. To use the framework, pick a topic, consider why it is a community concern, and plug topic and concerns into the diagram, filling in the various boxes and examining the connecting lines among them. This will give you a graphic description of the system that supports the issue. Tool #1 has an example of a filled-in framework diagram.

Task 7: Develop Locally Appropriate Indicators

The goal here is to take the connections that you mapped in the last task and turn them in to quantitative (i.e., expressed in numbers) indicators (measures) that will make it possible for you to track changes in various contributing factors, in individual issues, and in overall environmental health.

Develop a list of potential indicators. Begin by taking each factor you filled in on the framework diagram and translating it into a measure. If wearing protective gear in a particular job was a contributing factor, for instance, the indicator for it might be the percentage of workers wearing protective gear on the job. Tool #2 has an example of a filled-out framework map translated into indicators.

Depending on the complexity of the issue, you may have a large number of potential indicators. How will you decide which you’ll use?

Identify key indicators based on selected criteria. The indicators you choose should make sense in terms of local conditions, and should meet some other basic criteria. They should be simple, each clearly measuring just one thing. They should be understandable to the team and the public, and should reflect team agreement. Each should be acceptable to the community and address its concerns. Indicators should be measurable – able to be expressed in numbers and to be compared. And finally, indicators should be defensible, clearly showing a relationship between contributing factors and environmental health status.

Another description of good indicators can be found in Creating Objectives. It’s abbreviated SMART + C: Specific, Measurable, Achievable, Relevant, Timed (with a date for completion), and Challenging.

Task 8: Select Standards Against Which Local Status Can be Compared

While indicators allow you to see whether there are changes in the chosen issues over time, the question remains as to what is an acceptable or “good” level to reach for. There are few generally accepted standards that apply to environmental health, but some possibilities exist, and others can be generated locally.

Identify externally driven standards. The Guidebook gives some possible sets of standards, but none was developed later than 1996. The environmental health objectives of Healthy People 2020 might be helpful. Another possibility is to use for comparison state or federal levels or percentages of people affected by the issue, where such measures are available.

Agree upon locally appropriate standards. There may be current data available to provide a starting point (the number of children with unacceptable lead levels in their blood, for example, or the percentage of people in the community who suffer from respiratory illnesses). If a goal is to eliminate lead paint and other lead contamination, for instance, it might be reasonable to set a standard of no new cases of children with elevated blood lead levels after a certain date. A more difficult issue – e.g., respiratory illness tied to air quality – might have less ambitious goals, since the community may have less control over its environmental causes. Factories hundreds of miles away or thousands of cars a day traveling on interstate highways that run through the community may be major factors in determining air quality, and are probably beyond the ability of the local PACE EH effort to influence significantly.

Task 9: Create Issue Profiles

The point of this task is to describe all issues in similar terms, so that it will be easier to compare them when prioritizing them as part of the next task.

Adopt a standardized format for organizing information. The Guidebook provides a sample format that organizes each issue around the aspects of it the team has already explored: its scope, its background (local conditions and community input), the external and local standards the team has chosen, its community-specific indicators (including environmental health status, affected populations, exposure factors, environmental agents/conditions, contributing factors and behaviors, and public health protection factors, all from the issue map), sources of data about it, and the team’s analysis of it.

Gather information. Much of the information necessary may already have been gathered. Try to get similar types of information for each issue, so they can be easily compared. Federal, state, and community-by-community statistics; scientific background supplied by members of the team or a local university; local history of the issue related by key informants – all of these and many more types of information may go into the overall package.

Collect data for locally developed indicators. Here again, many sources will probably be needed, and a lot more of them will rely on the team’s own data-gathering. Both archival – federal, state, and local statistics, census data, etc. – and original sources are necessary, so team members may be interviewing and surveying community members, conducting forums and focus groups, and tracking down local organizational and institutional data (police and hospital records, numbers of local people using food stamps, participation in various human service programs) in order to flesh out various issues and develop profiles.

Develop a summary statement. Finally, prepare a description of each issue explaining it and summarizing the data you’ve collected in each category. You’ll use these statements in the next task.

Task 10: Rank issues

Now, it’s time to rank the issues: how do the issues the team has identified stack up in terms of their importance to the health of the community?

Determine the purpose of ranking. What are you trying to accomplish in your ranking? Is it more important that the rankings reflect the perceptions of the community, that they identify the issues associated with the most immediate health problems, that they pinpoint the issues that most seriously affect particular populations (children, the poor, racial minorities)? Each of these intentions calls for a different emphasis when ranking issues.

Decide on ranking criteria. It’s important, if you’re hoping to rank issues rationally, to compare them according to the same criteria. Tool #3 shows the Guidebook's worksheet to get started, but more discussion and more or different categories are likely to be needed in many communities. Some common criteria might include:

• The importance of the issue to the community
• The seriousness of the issue (Are people likely to die if it isn’t addressed immediately, for instance?)
• Whether it affects a geographically or ecologically sensitive area
• Whether it affects a particularly vulnerable population
• How much real data is available or can be obtained about it
• Whether there are policies in place that relate to it or regulate it
• How well the community at large understands the issue, and how strongly it will support addressing it

Select a method for ranking. This is really an extension of the first two parts of this task. Once you have a set of criteria, you have to decide how you’ll use them. Will you score each with a number, with a value (e.g., 1-5, with 1 being unimportant, 5 being very important; or 1 for a yes, 0 for a no), or simply rank issues in order after considering their positions on each criterion? Will one criterion be worth more than another because of your purpose in ranking? (For example, should the score for importance to the community be multiplied by 2 if you’ve decided that community perception is a deciding factor?)

Rank the issues. Will the team as a group score issues, or should each member score them individually, with the results added or averaged afterwards? In addition to scoring, ranking may require a good deal of discussion and back-and-forth on the part of the team. Ultimately, ranking is a matter of opinion – there are generally no pure right answers – so the process will benefit from team members explaining their reasons for ranking as they do, and factoring those reasons into the final result.

Task 11: Set priorities for action.

Priorities are different from ranking in that they will identify the issues the team will actually adopt to work on. The process is similar to that for ranking.

Determine local priority-setting criteria. The criteria in this case are meant to be practical as well as based on the rank of the issue. They include such categories as political and public support for the issue, the likelihood that the community can have an effect on it, the legal implications of tackling it, the consequences of not addressing it, and the community’s perception of the risk it poses. Tool #4 from the Guidebook provides a worksheet as a starting point.

Select a method for prioritizing. As for the previous task, this is a matter of how the team will score categories, what weight it will give to each, and how it will determine an overall score for each issue.

Determine priorities. Finally, the team will come up with a list of the issues it intends to work on. Again, there have to be decisions about how this will be done – solely by scores, whether averages or totals; through discussion of the scores and the issues; by some agreed-upon voting procedure; etc. How many issues are on this final list depends upon the team and community resources and the ease with which it seems issues can be resolved. The number might be relatively large if the plan is to work on one, then the next, until all have been addressed, with the understanding that such a plan may take several years – even a decade or more – to carry out. If the time line is shorter, the list of issues should be shorter as well – probably no more than two or three.

Task 12: Develop an action plan.

Once the issues to address have been chosen, the CEHA team must plan how that can be done. We’ll look briefly at the Guidebook steps in that process. (See also Chapter 8, Developing a Strategic Plan.)

Develop goals and objectives. For each issue, long-term goals (final outcomes) and shorter-term objectives (what has to be done to accomplish the goals) have to be determined. It’s often helpful to institute a participatory process for this, either by including more community people on various subcommittees or by asking for ideas and opinions from the community and acting on what they say.

Identify contributing factors. The team has already done this in Task 7.

Identify possible interventions and prevention activities. How will you go about changing the situation? Which factors can be affected by what interventions? What can be done with the resources available to the community?

Identify community assets. What institutions, organizations, people, facilities, and skills already exist in the community that can contribute to the effort?

Identify potential barriers. What are the legal, logistical, geographic, social, physical, political, and economic factors that might make addressing a particular issue difficult, and how can they be countered?

Select an intervention(s)/activity(ies). Decide what the team will actually do.

Determine resource needs. What are the funding, personnel, skills, and time needs to carry out the proposed interventions, and where will they come from?

Identify potential partners. Identify and bring in the organizations, individuals, institutions, businesses, and government officials and agencies that are needed or can help the team reach its goals.

Provide training. Determine what training is needed, and for whom, in order to turn the plan into reality, and arrange for that training to take place.

Develop timeframe. This is not just an overall timeframe, although that’s part of it (e.g., the effort will take a total of three years.) There should be a target for each phase of the plan – recruiting of partners, hiring (if necessary), completion of training (if necessary), determination of baseline data for evaluation, start of implementation, etc.

Determine measures of success. What are the specific measures the team will aim at? (By x date, x number of children will receive immunizations. By x date, the prevalence of the issue in the community will have been reduced by 15%.)

The Tool Box would add here the development of an evaluation of the implementation of whatever interventions or other activities are part of the action plan. Monitoring and evaluation of the process, impact, and outcomes of the implementation are an important part of taking action, and they should start at the very beginning of any implementation. They allow you to see where you need to adjust, add, change, or scrap elements of what you’re doing in order to improve effectiveness. Chapters 36, 37, 38, and 39 have more on evaluation.

Task 13: Evaluate progress and plan for the future

As with any process or initiative, it’s crucial to evaluate what you do.

The Community Tool Box would suggest that your evaluation plan be one of the first things you tackle in setting up the PACE EH effort, so that you can monitor your activities and progress from the very beginning.

Agree on the questions to be answered by the evaluation. What do you want to know about the assessment effort? Will you examine the process (the degree of involvement and collaboration among the stakeholder groups and individuals, how well timelines were observed, how work was distributed, how efficient the process was, etc.); the impact (what you actually did – e.g., conducting a certain number of interviews, distributing and receiving back a certain number of surveys); and/or the outcomes of the assessment (how close the effort came to meeting its goals, progress on implementation, other results that are important to the community, such as improved collaboration among various sectors or agreement to continue the assessment effort indefinitely)?

Evaluate the success of the assessment process. How well has the assessment process served the community by making possible the addressing of important environmental health issues? Have structures been created that will help the community continue to improve environmental health? Did the assessment process raise the profile of environmental health in the community and among the organizations, agencies, and officials that make up the public health system?

Begin preparations for ongoing community-based environmental health assessment activities. This is the PACE EH version of advice you’ll see everywhere in the Community Tool Box: keep at it indefinitely. Conditions change, formerly unknown environmental health issues surface, populations shift. Communities have to keep up with these changes, and to continue to plan and to alter their current activities and interventions to match emerging needs. The PACE EH process can and should be conducted on an agreed-upon regular basis, as should monitoring the community’s environmental health status, demographics, and other environmental-health related areas. In that way, communities can see issues developing, and address them before they become problems. Continuing the process can help make yours a healthy community.

In Summary

PACE EH provides a structure for assessing a community’s environmental health and identifying current or emerging issues in that area. Because of its emphasis on collaboration and community involvement, it creates a climate for community problem-solving, not only in relation to environmental issues, but for community issues in general. PACE EH also sets the stage for regular assessments, so that environmental health remains in the community’s consciousness, and doesn’t have to be approached as if it’s new every time there’s an environmental health issue to address. Overall, the use of PACE EH can be a vital part of creating and maintaining a healthy community.

 

We encourage the reproduction of this material, but ask that you credit the Community Tool Box: http://ctb.ku.edu/.