Exploring a Model to Address Children s Environmental Health Issues in Africa

Transcription

1 Exploring a Model to Address Children s Environmental Health Issues in Africa Environmental Public Health Leadership Institute Fellow(s): Aurora 0. Amoah; MPH Research Scientist; The George Washington University 2100 M St. NW, Suite 203 Washington, DC, eohaoa@gwumc.edu aoamoah@gmail.com Mentor(s): Mentor:-Palak Raval-Nelson, PhD, MPH Chief-Office of Food Protection Philadelphia Department of Health (Acknowledgements): Martha Berger US Environmental Protection Agency Paula Wilbourne Davis, MPH CHES- Association for Occupational and Environmental Health Clinics (AOEC) Kathy Kirkland, MPH- Association for Occupational and Environmental Health Clinics (AOEC)) Jerome Paulson, MD- Children s National Medical Center (CNMC)& The George Washington University (GWU) Lisa Gilmore, MSW MBA- Academy for Educational Development (AED) Benjamin Gitterman, MD- Children s National Medical Center(CNMC)& The George Washington University (GWU) Tee L. Guidotti, MD MPH-The George Washington University (GWU) Nsedu Obot Witherspoon, MPH-Children s Environmental Health Network Prentiss Ward, MS- US Environmental Protection Agency R111 Laura Werner, MPH-Agency for Toxic Substances and Disease Registry R111

2 EXECUTIVE SUMMARY: Children are not little adults and their physiology and behavior renders them more susceptible to environmental pollutants than adults. As a result, exposure to environmental health pollutants may lead to increased toxicity and fatal outcomes among children. Yet there are no exposure guidelines developed to protect children and children s environmental health issues are yet to gain priority in health research. The Pediatric Environmental Health Units (PEHSU) model was developed in 1998 in the United States, following an executive order by President Clinton on children s environmental health in There a 10 units located across the nation. The goal of these units are to improve environmental heath outcomes among children by promoting a network of environmental health specialists who address the knowledge gap in children s environmental health among medical and other health professionals through education. The model is considered successful in the United States, yet efforts to develop similar models in other global locations, especially in the less advanced countries has been difficult. Africa has the highest rate of child mortality and morbidity resulting from environmental health pollutants. Introducing a variation of a Pediatric Environmental Unit model in Africa will provide an evidence based intervention of addressing the high prevalence of environmentally related ailments and mortality among African children. A systems thinking approach is used to examine why a gap exists between the perceived knowledge of children s environmental health and the desired level of visibility of the PEHSU model in Africa? The problem is described by graphing identified variables over time and explored using the limits to success archetype. The resulting project and logic model derived from the systems thinking exploration targets all of the 10 essential environmental health services. The proposed project aligns the United Nations Millennium Development Goals (MDG) with the national environmental health goals and indirectly meets the Healthy people 2010 goals. The recommended next steps are to convene a group of experts within the PEHSU network interested in a development initiative in Africa in order to examine the fragmented initiatives and develop a systematic approach in introducing the Pediatric Environmental Health Unit model in Africa.

3 INTRODUCTION & BACKGROUND: Children s Environmental Health Children are not little adults and their physiology and behavior renders them more susceptible to environmental pollutants than adults. Infants and children consume more water than adults. Therefore any contaminant in their water supply will taken be in greater proportion by children than adults. Children are usually shorter than adults, and their breathing zones are nearer to the ground, making them more susceptible to heavy gases that tend concentrate closer to the floor such as mercury. Additionally, they consume more oxygen and produce more CO2 than adults; therefore making a child s exposure to air pollutants greater than the adult. The resulting outcome from pollutants including harmful chemical exposures are diverse and can result in mortality and prolonged or chronic morbidity among children. 1 The Pediatric Environmental Health Units (PEHSU) 2 There are no exposure guidelines developed to protect children and children s environmental health issues are yet to gain priority in health research. 3 Prior research has shown an existing gap in the knowledge of children s environmental health issues among medical and allied health professionals. 4 In 1998, Pediatric Environmental Health Specialty Units were implemented primarily to address the knowledge gap in environmental health among medical and other allied health professionals. There are currently 10 units, one located in each EPA federal region across the country. The goal is to ensure that children and communities have access to special medical knowledge and resources for children faced with a health risk due to a natural or human-made environmental hazard PEHSUs are academically based, typically at university medical centers. The PEHSUs form a network capable of responding to requests for information throughout North America. Due to the diverse nature of health conditions resulting from environmental exposures, the PEHSU network is comprised of experts in pediatrics, allergy/immunology, neurodevelopment, toxicology, occupational and environmental medicine, nursing, and other specialized areas. PEHSUs collaborate effectively with families, non-governmental agencies as well local, state and federal partners. The basic services of the PEHSU network include community education and outreach; training of health professionals; medical consultation and referral to specialty care. The PEHSUs are overseen nationally by the Association for Occupational and Environmental Health Clinics (AOEC) and are funded by the Agency for Toxic Substances and Disease Registry and the US Environmental Protection Agency (EPA)

4 Figure 1: The role of the PEHSU program PEHSU Referral Educational Outreach Medical Advice & Consultation General Public Clinicians & Health Professionals Clinical Trainees. The Need for a Model to Address children s Environmental Health Issues in Africa It is important to address the burden of disease resulting from environmental health exposures in Africa due to the severity of the health outcomes and its impact on both the African continent and beyond. The six major classes of environmental risks for African children are: inadequate access to safe drinking water, poor hygiene and sanitation, disease vectors, air pollution, chemical hazards and unintentional injuries. Resulting health outcomes include respiratory infection, diarrhoea, measles, malaria, HIV/AIDS and malnutrition. The World Health Organization (WHO) estimates that up to 70% of children who die in Africa succumb to diseases linked directly or indirectly to these environmental risk factors. 6 In 2002 alone, 2.4 million lives were lost in Africa due to environmental related diseases. 5 A fifth of children born in Africa may not survive beyond their fifth birthday and those who survive maybe be hampered by environmentally related disabilities over a lifetime. 6 Also, forecasted climate changes are set to present new challenges and environmentally related disease such as asthma and malaria are expected to rise. 7 Increased prevalence of these ailments stands to decrease the quality of life for African children. It will also affect the future availability of an effective workforce necessary to achieve development goals on the African continent. Arrested development on the African continent is a continued burden on donor countries, such as the United States. Also, technology has made all areas of the globe easily accessible and infectious diseases are easily transported beyond the point of infection. It is therefore important to develop partnerships and effective strategies to addresses environmental health issues among African children. Given its success in the United States, The PEHSU model presents an evidence based approach to address children s environmental health issues among African Children..

5 Efforts in Applying the Pediatric Environmental Health Unit Model Globally There have been efforts among the PEHSU network to expand the model globally. Specifically PEHSU staff have worked with the funding agencies to conduct education on children s environmental health concerns internationally. Children s Environmental Health centers have been initiated in Canada, Mexico, Spain and Argentina. The Units in Canada, Argentina and Spain are still in operation. The Unit in Mexico recently closed. In Korea, The Ministry of Environment has been exemplary in implementing 11 environmental health centers around the country to conduct research and manage children s environmental health diseases. Specific to Africa, there have been efforts to rally political support to initiate the introduction of children s environmental health trainings and units. These efforts are yet to result in the implementation of children s environmental health units or training sessions for African health professionals. Problem Statement: The Pediatric environmental health units have proven effective in addressing children s environmental health issues in the United States. However, in Africa, there is limited knowledge and effort to address the negative impact of environmental risk factors to children. The question that the paper seeks to address is: Why is there a gap between the perceived knowledge of children s environmental health and the desired level of visibility of the PEHSU model internationally?

6 Behavior Over Time Graph: Desired Level of Presence Internationally Need for Children s Environmental Health /PEHSU services Perceived level of clarity on PEH issues Time Resources Resources: Both financial and human resources are limited. Financial resources for the entire PEHSU network have remained almost stagnant. A few international PEHSUs are receiving funding directly from EPA. However new experts need to be trained to sustain the knowledge on children s environmental health. Additionally limited funding means that personnel have to find other ways to supplement their income, thus reducing their time allotted to PEHSU responsibilities Perceived Level of Clarity on (Children s Environmental Health) CEH: Children s environmental health is not a priority area in health research. The expert network is small in comparison to other health specialties. In the last 10 years efforts by PEHSU network together with World Health Organization (WHO) initiatives has led to more publications and trainings on CEH. Yet additional research is necessary and more information is needed to effectively address the impact of environmental health pollutants on children worldwide. Need for PEHSU services internationally, (especially in developing countries): The burden of diseases resulting from environmental health pollutants is highest in Africa. Concerns over climate change issues project even more harmful exposures and negative outcomes. Therefore knowledge and training to health professionals, and the community is necessary to address these forecasted problems. Desired Level of presence internationally (especially in developing countries): It is important for the PEHSU to sustain a constant and high visibility in order to engage in knowledge sharing and collaborate with partners internationally to reduce environmental diseases among children in developing countries.

7 Causal Loop Diagrams and applicable Archetypes: Limits to Success Int. Centers will take the initiative to implement projects and will continue to sustain the projects with own funding and expertise. Lack of financial, human and technical expertise CEH results s R s s Implementing the PEHSU model internationally Delay B Gvt and Health Expert Support in Country o s Expertise and funding support will be provided via foreign aid agency Funding Virtuous Cycle Limiting Process Overview of Limits to Success diagram: The Limits to Success diagram consists of a reinforcing loop (R), the growth of which, after some success, is offset by the action of a balancing loop (B). In the Virtuous cycle, the implementation of the PEHSU model internationally is fuelled by the existence of funding and CEH expertise. The mental model in this loop or the general assumption is that the international centers will take the greater initiative to sustain the projects their on their own after initial assistance. The limiting process interacts with the virtuous cycle to slow growth. The limiting state is the lack of financial, human and technical expertise. This then influences the government and health expert support. The lack of government and health expert support acts as a slowing action. This then influences the Implementation of PEHSUs internationally, after a short delay. The mental model associated with the balancing loop is that expertise and funding support will be provided through foreign aid and not by the target government.

8 10 Essential Environmental Health Services: Efforts to address the environmental health concerns internationally meet all of the 10 essential environmental health services. 1. Monitor Health: The current PEHSUs monitor environmental health status through individual data collection. In implementing this model elsewhere, it is important to engage in monitoring of the environmental health issue to better direct the intervention to the right individuals. 2. Diagnose and investigate: One of the primary functions of this project will involve diagnosing children exposed to environmental health pollutants and subsequently help to address the health hazards in the community. 3. Inform, educate, and empower: Another primary function is the education of health professionals to increase their knowledge and ultimately to enable them to improve the diagnosis and management of environmental health related diseases among children. 4. Mobilize and Identify: Building a stakeholder consensus is crucial to the overall success of the project. Government agencies on both sides have to be involved in pushing the agenda before the models can be implemented in selected communities. 5. Develop policies and plans: Currently PEHSUs have polices and plans that allow for effective functioning. In implementing a similar model elsewhere, this aspect will be essential to the success of the model. 6. Enforce Laws: Addressing safety for children often leads to development and enforcement of laws such as housing codes. The prime example in the United States have been the elimination of domestic use of lead paint, which was done through legislation and continues to be improved on and enforced at the local and state level. 7. Link people to and provide care: The current PEHSU model provides medical services and when needed is able to link families to appropriate services within their community. This involves partnership with several local organizations in an effort to leverage funds to improve health outcomes. This project will seek to maintain this aspect of the PEHSU. 8. Assure a competent workforce: Training of health professional in environmental health issues will assure a competent workforce for all governments involved 9. Evaluate: Evaluation in necessary to access the impact of the intervention on the target community. 10. Research: Given the limited research on children s environmental health, implementation of a new model will research and data collection on children s environmental health.

9 International and National Goals Supported The target audience is international. The proposed project directly addresses the United Nations Millennium Development Goals (MDG) and aligns with some of the goals of the National Strategy to Revitalize Environmental Public Health Services. The Healthy people 2010 goals are indirectly addressed. Additionally, the project addresses all the competencies of local environmental health practitioner. The Millennium Development Goals (MDGs) are eight goals to be achieved by 2015 that respond to the world's main development challenges. The project directly addresses 4 of the 8 goal. They are: Goal 4: Reduce child mortality ; Goal 5: Improve maternal child health; Goal 6: Combat HIV/AIDS, malaria and other diseases; Goal 8: Develop a Global Partnership for Development. 8 The goals addressed within the National Strategy to Revitalize Environmental Public Health Services are: Goal II: Support research to define effective approaches to enhance environmental public health services; Goal III: Foster Leadership ; Goal VI: Create Strategic Partnerships; Goal IV: Communicate and Market. In addressing the MDGS and the National Strategy to Revitalize Environmental Public Health Services goals, the project indirectly addresses the first overarching Healthy People 2010 goal to increase the quality and years of health life among the US population by limiting the possibility of transfer of infectious diseases from the African region to the United States. The project addresses the entire core Competencies for Local Environmental Health Practitioners. Assessment will be carried on from initiation throughout the project period. Data analysis and evaluation are essential in determining the effectiveness of the intervention and sharing results among stakeholders. Management will involve general project management as well as securing economic and political consensus among several stakeholders. Finally the communication aspect involves the education and communication among several health experts and to the target community and stakeholders.

10 Logic Model Program: Implementation of Pediatric Environmental Health Specialty Unit Model in Africa Situation: The Pediatric Environmental Health Specialty Units have been successful in bridging the gap among health professionals on children s environmental health issues and subsequently reducing the prevalence of environmentally related health issues in children. This model can be used to attain similar result in Africa where unsafe water, pollution, poor sanitation, inadequate waste disposal, insufficient disease vector control and exposure to chemicals claimed about 2.4 million lives in 2002 alone. 7 Inputs Activities Participation Outputs Outcome Partners: PEHSU CEHR-NIEHS WHO UNEP UNICEF CDC USEPA\ DOHs Medical Board Public Health Associations International development/ngos Staff: Medical Staff Environmental Health professionals Faculty Funding: Combined stream of funding from governmental and non governmental source Research and Technical expertise Convene an advisory board to assist in technical and logistical aspects of the project development. Assessment of sites for project locations: Regional centers will be identified for capacity building purposes and satellite sites in each country. Develop criteria for selection of trainees and future researchers in CEH Capacity building to increase knowledge of children s environmental health issues Capacity building among clinicians on children s environmentally related diseases Capacity building in research development: Curriculum to develop research skills among selected trainees Assumptions Commitment from partner organizations to participate in the process Target audience/ trainees will be readily and willingly participate in the program Policy makers and officials from regional locations and collaborating agencies Trainees Medical professionals Public health professionals Health Administrative personnel Advisory board with fair representation of technical expertise, logistical and regional knowledge from partnering agencies One indentified site per each geographic region (N, S, E, W) and satellite offices in DOH in each country. Developed criteria for selection of target health professional /trainees Developed curriculum for Train the trainer (TOT) program on CEH - Clinical management of EH related diseases - Developed curriculum for research development in CEH ISSUES Complete training sessions for 120 Health professionals/year: - 10 Health professional/region/5 years on TOT - 10 clinicians /region/5 years on management of EH related diseases in children - 10 Health professionals/ 5 years/ CEH research External Factors Program Funding Collaborating agencies organizational Influence on time allocation Cooperation among the listed agencies Short Term Outcome Increased knowledge of CEH issues in the African region Increased Knowledge on clinical management of CEH diseases in affected children Increase knowledge and identification on research possibilities on CEH issues for the African region Mid-Term Outcome Ability to train other health professionals in CEH issues Ability to manage clinical cases in CEH Ability to undertake research in CEH Long term outcome/impact Rev. 7/09 Decrease in environmental health ailments in children and increase human resource to support sustainable development in the African region

11 PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES: Program Goal: To implement the Pediatric Environmental Health Specialty Unit model in Africa in order to reduce the prevalence of environmentally related diseases in the child population in the African region Health Problem: Diseases caused by changes in the environment accounts for a significant number of deaths in the African continent. In 2002 alone unsafe water, pollution, poor sanitation, inadequate waste disposal, insufficient disease vector control and exposure to chemicals claimed about 2.4 million lives. 7 Outcome Objective: By end of 5 year project period, environmentally related diseased will be reduced by 25% among children. Determinant: The number of trained health professionals in children s environmental health per region per year. Impact Objective: By end of the fifth year, 120 African health professionals will have an increased knowledge in CEH issues and ability to utilize this knowledge to prevent and mitigate adverse effects from environmentally related diseases. Contributing Factors: 1. Limited partnership among stakeholders/ governmental and non governmental agencies on dealing with CEH issues in Africa. 2. Lack of both financial and educational resources to support CEH trainings for Health Professionals in Africa 3. Lack of technical expertise in CEH training, research and clinical management of Environmentally related diseases among African heath professionals Process Objectives: 1. By the end of year 1, have a collaborative advisory group comprising 20 individuals in place to assist with technical and logistical aspects of project implementation Event: Partnership development Activities: Contact both governmental and non governmental groups to develop advisory group Contact Medical and Public Health organizations in target countries Select experts in PEHSU network Select and convene advisory group meeting Develop approach to improving financing for CEH health projects. 2. By end of year 2, develop and test 3 sets of curriculum on train the trainer modules, research and clinical management of disease in CEH.

12 Event: Develop curriculum for training sessions Activities: Convene CEH technical experts a. Break into 3 working groups on research, clinical management and knowledge training. b. Conduct needs assessment of target health professionals c. Develop framework for training sessions d. Develop content of training manuals e. Pilot test training materials 3. By Year 5, increase capacity among 120 health professions on CEH knowledge, research and clinical management among African health professionals Event: Implement training programs Activities: Develop criteria for selection of trainees Select training sites Implement training programs Evaluate trainings with pre and post tests Follow up on impact and outcomes through Department of Health reports NEXT STEPS: 1. The immediate next step is to determine the actual level of involvement among the pediatric environmental health network with the international centers and subsequently identify those experts with the capability and skills to engage in international environmental health training in Africa. 2. Research and identity the fragmented and parallel efforts among the different US government agencies and the United Nations agencies such as the WHO and UNICEF, to collaboratively address the development of a model to address children s environmental health issues in Africa 3. Identify all partners within the US government and internationally and work to building political support among the target governments agencies as well as professional member organizations in Africa 4. Indentify a secure funding source for the next 10 years, or five years minimum, before embarking on the implementation of international sites.

13 LEADERSHIP DEVELOPMENT OPPORTUNITIES: Aurora 0. Amoah Development paragraph The Fellowship provided an opportunity for comprehensive development at both the personal and professional level. Public health requires working with teams, and leadership skills are essential to the proper functioning of teams. Interaction with my assigned coach and mentor was extremely beneficial in enhancing my leadership skills. The core emphasis was on improving my communication skills, which is essential to a leader in motivating and arriving at a consensus among a team. The coach and mentor recommended strategies and reading material to cope with difficult situations. Coupled with the conflict management courses required by the program and the cross cultural communication course I elected to take, I was rewarded with better outcomes when engaging in difficult conversations or interacting with difficult people. The systems thinking sessions emphasized a systemic way of developing a holistic and workable solution for a problem. Most often, when faced with a problem, we gravitate towards a comfortable quick fix. The systems thinking approach is systematic is helping to indentify the problems and then selecting an appropriate solution with sustainable outcomes. Overall, the introduction to systems thinking and enhancement of my leadership skills improved my personal outlook, subsequently enhancing my productivity within the organizations that I work in.

14 ABOUT THE EPHLI FELLOW(s) Aurora O. Amoah, MPH is a Research Scientist with the Center for Risk Science and Public Health of the George Washington University School of Public Health and Health Services (GWU SPHHS). She is concurrently enrolled in Doctor of Philosophy (PhD) program at the Department of Health Systems Management of Tulane University School of Public Health and Tropical Medicine (TU SPHTM) and a Masters in Public Policy (MPP), expected May 2010 from the George Washington University Trachtenberg School of Public Policy and Public Administration (GWU TSPAA). Ms Amoah has been funded by both the Environmental Protection Agency (EPA) and the Centers for Disease Control and Prevention (CDC) to develop healthy home programs targeted to children in low income families in the District of Columbia. She collaborates with the Children s Environmental Health Network and the District of Columbia Department of Health on these projects. Previously she served as the project coordinator for the Region 3 Pediatric Environmental Health Specialty Unit (PEHSU) located in the George Washington University (GWU) and affiliated with both the University and the Children s National Medical Center (CNMC). As the project coordinator, she managed all aspects of the project from development to implementation and evaluation. Since 2005, she has been instrumental in planning and coordinating the annual continuing education conference on children s health and the environment targeted to a 100 health professionals within the Mid-Atlantic Region. Additionally, she planned and coordinated the State of Asthma in the District workshop for stakeholders in the District and partnered with the National Capital Asthma Coalition to develop a comprehensive asthma management manual and training session for District school administrators and nurses. She is an invited member of the DC Asthma Steering Committee and the DC Lead Elimination Taskforce In her previous roles, Ms Amoah worked with the Adolescent School Health Initiative program (ASHI) at the Louisiana office of Public where she developed an evaluation plan for the Baton Rouge, LA School Based Health Centers and managed the pilot of a pediatric obesity management program in the School Based Health Centers.

15 REFERENCES 1 Etzel, R.A. (AAP) Pediatric Environmental Health 2003 American Academy of Pediatrics 2 The Association for Occupational and Environmental Health Clinics(AOEC). Pediatric Environmental Health Specialty Units. Retrieved May 26, 2009 from 3 Patrick Breysse. Air Pollution in Schools. Presentation at the 6 th Annual Conference on Children s Health and the Environment, September 11, McCurdy L.E., Roberts J., Rogers B., Love R., Etzel R., Paulson J., Obot-Witherspoon N., Dearry A.C. (2004) Incorporating Environmental Health into Pediatric Medical and Nursing Education. Environmental Health Perspectives, 112: United Nations Environment Programme (UNEP).WHO and UNEP Join to Combat Environment-related Disease in Africa. Aug. 22, 2008 Retrieved Jan 3, 2010 from 6 Consultation on Children s Environmental Health in Africa. Feb Retrieved October 20, 2009 from 7 UNICEF (2008).Climate Change and Children: A human Security Challenge From 8 The Millennium Development Goals Retrieved Jan 20, 2010 from