Using the PACE EH model to mobilize communities to address local environmental health issues--a case study in Island County, Washington.

Introduction

Island County, a small rural county in Washington State, used the Protocol for Assessing Community Excellence in Environmental Health (PACE EH) model to build capacity in the 10 essential services of environmental health and to initiate a community norm for widespread, broad-based citizen participation in environmental health policy development. PACE EH is a community-based process that engages citizens in local environmental health issues, and Island County is one of several communities nationwide that have successfully implemented PACE EH (National Association of County and City Health Officials [NACCHO], 2002).

Island County comprises seven islands located in Puget Sound approximately 30 miles north of Seattle and 50 miles from the Canadian border. While the population of nearly 80,000 residents is faced with some unique environmental issues such as two federally designated sole-source aquifers, a large naval air base, and 250 miles of shoreline, the environmental health programs have in the past followed traditional methods of regulation, inspection, and enforcement.

The Island County Health Department (ICHD) developed the Island County Environmental Health Initiative (ICEHI) to embrace the philosophy and methodology of PACE EH by engaging communities in identifying issues of local importance. By utilizing and enhancing the knowledge, independent resources, and skills of community members as part of the ICEHI project, health department staff have been able to expand on existing resources to collect environmental health data, analyze issues, set priorities, develop action plans, and implement activities identified in those plans.

Implementing PACE EH in Island County

PACE EH is an iterative process that involves the completion of 13 tasks (NACCHO, 2000). Further reading on the process used to develop PACE EH can be found in a paper by McDonald, Treser, and Hatlen (1994). Island County strengthened capacities related to PACE EH by emphasizing specific tasks that involved characterizing the community (tasks 1-4), identifying environmental health issues (tasks 5-10), and developing action plans (tasks 11-13). Table 1 identifies ICEHI project activities associated with PACE EH tasks and shows how those tasks correspond to the 10 essential services of environmental health (Baker et al., 1994).

Community Characterization 

The development of the PACE EH process benefited significantly from the existence of Island County's Community Health Advisory Board (CHAB). CHAB was formed in 1993 as a citizen advisory committee to advise the local board of health on matters of public health policy. Recognizing that an environmental health assessment would require significant additional community representation and resources, CHAB identified PACE EH as a priority for addressing local environmental health issues.

As part of the PACE EH process, ICHD's first task was to develop an asset map for Island County (see www.islandcounty.net/health/EHA/toolkit.htm). The purpose of the asset map was to identify existing institutions, social structures, and organizations that contribute to the social network that binds the community together. The map was developed through community networking and investigation of phone books, social organization literature, and documentation from other public agencies. The map identified 114 local institutions and 57 citizen organizations comprising businesses, parks, health care agencies, the legal system, media, libraries, schools, transportation, social services, colleges, service organizations, charitable agencies, interest clubs, and faith-based communities.

On the basis of the mapping exercise, ICHD incorporated economics, social organization, and environment into a definition of the community of Island County (Task 2) and developed the Environmental Health Assessment Team (EHAT) matrix, which was used to identify stakeholder interests unique to Island County (i.e., social, political, and organizational) that should be represented by members on the assessment team (accessible via www.islandcounty.net/health/EHAT/toolkit.htm).

Working from the EHAT matrix and a compiled list of desired participants, ICHD staff solicited community interest in completing an application to join EHAT (Task 3). The purpose of the application was to communicate the applicant's environmental health expertise, community interests, and stakeholder representation. ICHD staff used a number of methods to solicit interest, including advertisements in the local media and a significant number of presentations at social organization events, both aimed at communicating the concept of the community-based environmental health assessment process.

The outreach to the community elicited nearly 50 applications from community members desiring to participate in the PACE EH process. The project coordinator, a member of CHAB, and a representative from the local board of health interviewed applicants and selected team members on the basis of their expertise, their willingness to contribute time and energy to the project, and the stakeholders' interests they represented relative to those represented by other applicants. The selection process yielded an assessment team composed of 26 members representing a broad spectrum of the community. The Island County Board of Health appointed each of the team members.

The first task of EHAT was to develop goals, objectives, and a vision statement (Task 4). As shown in Figure 1, the goals and objectives focused on initiating positive changes in the community, addressing locally appropriate environmental health issues, using community resources, and receiving both community and political support. Underlying the goals and objectives was a desire to increase public awareness of environmental health and increase communication among existing programs, elected officials, and the public.

[FIGURE 1 OMITTED]

Environmental Health Issue Identification

In order to begin the dialogue concerning locally appropriate environmental health issues, EHAT developed a list of over 150 potential issues (Task 5). The list was derived from a variety of sources, including a baseline EHAT knowledge assessment, interviews with ICHD staff, The Health of Washington State (Washington State Department of Health, 2002), Island County's Special Report on the Health of Island County (1996), Environmental Health and Global Health Survey (University of Washington, 2002), and the Pew Charitable Trusts Public Opinion Research on Public Health, Environmental Health and the Country's Public Health Capacity to Adequately Address Environmental Health Problems (1999). EHAT decided to limit the issue list to four environmental factors in order to focus its finite resources on select activities and then to prioritize the items on the list by applying specific criteria within an analytical framework (Task 6). These criteria focused on the relationship between the environmental risk and human health, the local population potentially affected by the environmental influence, the presence of the environmental risk factor in Island County, and the ability of the community to effect change in the relationship between the risk factor and public health given limited resources. The latter proved to be a significant factor in the evaluation.

The four environmental health issues that received priority for further consideration were West Nile virus, arsenic in drinking water, illegal dumping and littering, and the walkability of Island County as it relates to opportunities for physical activity. The PACE EH toolkit (available at www.islandcounty.net/health/EHAT/toolkit.htm) illustrates the sample framework for all four issues. To obtain insight into how each risk factor or agent could be reduced in Island County, EHAT developed issue profiles for each of its priority issues (Task 9). The profiles identified the contributing factors, environmental agents, exposure factors, affected populations, public health protection factors, and environmental health status for each environmental health issue. Indicators and standards were then identified by EHAT for use to evaluate the effectiveness of future intervention strategies (tasks 7 and 8). For its top priority of illegal dumping and littering, EHAT set a standard of no illegal dumping and littering in Island County; the community-specific indicator is the amount of illegal dumping and littering in Island County. EHAT measured a walkable Island County according to two separate standards: 1) Community destinations can be reached by pathways, and 2) connective areas by which pedestrians, or people using assistive mobility devices, can safely travel. As indicators of walkability, EHAT selected the number of miles of connected pathways between major community destinations and the percentage of "passing" walking audits, showing that connective pathways are safe and pleasant to walk along.

To further focus community resources, EHAT narrowed the four issues down to two priority issues using 22 ranking criteria that were selected on the basis of local data, including morbidity and mortality, the ability of alternative public or private resources to address the issue, and the likelihood that community intervention would elicit change in the risk factor or the affected population (Task 10). The scorecards for ranking and prioritization are available at www.islandcounty.net/health/EHAT/toolkit.htm. According to application of the criteria and a weighted vote by EHAT members, illegal dumping and littering ranked as the highest-priority issue, while walkability ranked second.

Action Plan Development

To fully understand the magnitude of two top-priority issues, EHAT brought together local experts, public officials, and affected populations at community forums to identify gaps and barriers and to brainstorm solutions for addressing both illegal dumping and littering and the walkability of Island County (Task 11).

Illegal Waste Dumping and Littering

EHAT's two dumping forums were attended by EHAT representatives, elected officials, solid waste handlers, resource management agencies, educators, and environmental health professionals. The outcome of the two forums was the identification of three intervention strategies for each of the areas of education, enforcement, and economics. EHAT developed its action plan on the basis of nine intervention strategies identified in the forums, with particular emphasis on use of community-based resources (Task 12).

Walkability

EHAT developed its walkability action plan independent of the forum process and geared the plan toward fostering partnerships and public education and encouraging local planning support for the development of opportunities for walking and physical activity As one of its project activities, EHAT sponsored a forum to identify the gaps and barriers that needed to be addressed for community members to be more active and to incorporate walking into their daily lives. Forum participants included EHAT members, elected officials, park and recreation managers, community walking groups, schools, transportation planners, and physical-activity coordinators. There is significant community support for a follow-up forum focused on recommending intervention strategies to increase opportunities for walking and physical activity, reducing the barriers that impede community members from walking, and educating the local community on the availability of walking opportunities and the benefits of physical activity (Task 12). In the meantime, EHAT and 1CHD staff are evaluating the progress of the ICEHI project and continuing project activities (Task 13).

Conclusion

Island County has enjoyed significant success with its use of the PACE EH process to develop a community-based environmental health assessment and implement locally appropriate action plans. ICHD staff attribute the success of the PACE EH process to 1) the assembly of an active, dedicated, community team; 2) the focus of the assessment on relevant community-identified environmental health issues; and 3) the development of action plans with realistic goals and solutions derived from the application of community resources. ICHD staff have detailed their process, outcomes, and lessons learned in a PACE EH toolkit for use by other local health agencies.

A significant investment of time, energy, and resources was required to mobilize the community to effect change in the environmental health of Island County. The EHAT members were purposely chosen to represent the demographic and stakeholder interests of the community and did not serve on the group as token representatives of existing environmental health programs or agencies. EHAT included representation from 21 of the 22 community interests identified in the EHAT matrix. Each member was dedicated to the project goals and made a commitment of time and energy for a minimum of three years following his or her appointment.

Early in the process of developing the governing and decision-making structure and ground rules for EHAT, it was discovered that the successes of the assessment team depended largely upon the support of elected officials for the assessment process and intervention strategies that followed the issue identification. For that reason, two EHAT members were chosen as board of health liaisons to interact with the board by providing updates on a quarterly basis and seeking input from the board during key decision-making steps in the assessment process. Board members were also invited to all of EHAT's meetings and to the forums held to address illegal dumping and littering and walkability. This interaction proved to be successful and has resulted in significant political support for most of EHAT's activities.

Since the PACE EH process relies on the development of community-based intervention strategies, the selection of appropriate priority issues determines the likelihood of success with any intervention strategy. The process used to select and prioritize environmental health issues in Island County was not without controversy and proved to be one of the more difficult tasks for EHAT. Community members bring with them to the assessment process preconceived notions about environmental health problems. When such notions, or biases, are present, objective evaluations of environmental health issues using a localized systems approach can allow for a meaningful prioritization process.

The ability of EHAT to prioritize local environmental issues depended less on the list of issues with which the task began than on the process used to reduce the list to a manageable size. Through many discussions, selection criteria were developed that removed the ability of community members to apply their own biases and focused the process upon local data and scientific certainty. The issue profiles that were developed for the top four issues further clarified the roles of science and local relevance in the selection process. Although issues such as global warming and sea-level rise were considered within the realm of possible environmental health issues, when the ranking process required participants to determine if community-based intervention strategies could lessen the severity of the issue, they were forced to focus on those local priorities.

Island County has benefited greatly from the application of PACE EH to identify and solve local environmental health issues. Today, our community members are much more cognizant of environmental health issues and support intervention strategies to address those issues. Other state and local health departments that wish to successfully implement PACE EH need to recognize that the community process is slow and requires an investment of staff resources and time. It is also imperative to understand that PACE EH successes depend on support for the process from health department staff, the community, and political institutions. With such support, the benefits of the PACE EH process far outweigh the investment.

Acknowledgements and disclaimer: We are extremely grateful to the 26 EHAT members who dedicated their time and energy to implementing the PACE EH process in Island County. In addition, we would like to acknowledge the Island County Board of Health for its support of the program. Special thanks go to Kerry McDonald, Nancy Farnsworth, and Valerie Matazzoni for providing assistance on ICEHI project activities. This article was supported by Grant #U50/CCU024319 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the Centers for Disease Control and Prevention.

Corresponding Author: Tim McDonald, Health Services Director, Island County Public Health, 1 NE 6th Street, Coupeville, WA 98239. E-mail: [e-mail].

REFERENCES

Baker, E.L., Melton, R.J., Stange, P.V., Fields, M.L., Koplan, J.P., Guerra, F.A., & Satcher, D. (1994). Health reform and the health of the public: Forging community health partnerships. Journal of the American Medical Association, 272(16), 1276-1282.

Island County. (1996). Special report on the health of Island County. Retrieved November 9, 2006, from http://www.islandcounty.net/health/CHAB/Special.htm.

McDonald, T.L., Treser, C.D., & Hatlen, J.B. (1994). Development of an environmental health addendum to the assessment protocol for excellence in public health. Journal of Public Health Policy, 15(2), 203-217.

National Association of County and City Health Officials. (2000). PACE EH protocol for assessing community excellence in environmental health: A guidebook for local health officials. Washington, DC: Author.

National Association of County and City Health Officials. (2002). PACE EH in practice: A compendium of ten pilot communities. Washington, DC: Author.

Pew Charitable Trust. (1999). Public opinion research on public health, environmental health and the country's public health capacity to adequately address environmental health problems. Baltimore, MD: Johns Hopkins, School of Hygiene and Public Health.

University of Washington. (2002). Environmental health and global health survey. Seattle, WA: University of Washington, School of Public Health and Community Medicine.

Washington State Department of Health. (2002). The health of Washington state. Retrieved November 9, 2006, from http://www.doh.wa.gov/HWS/.

Keith Higman

Celine Servatius, R.E.H.S.

Whitney L. Webber, M.S.

Tim McDonald, R.S., M.P.H.

TABLE 1 The Relationship Between the 10 Essential Services of
Environmental Health and the PACE EH Process

Essential Environmental Health    PACE EH       Activities Associated
Service                           Task Numbers  with PACE EH Tasks

 1. Monitor health status to       4-9          Assess the environmental
    identify community                          health needs of the
    environmental health                        community
    problems                                    Assess the environmental
                                                health determinants in
                                                the community
 2. Diagnose and investigate       5-9          Investigate the
    environmental health                        occurrence of
    problems and health hazards                 environmentally related
    in the community                            events
 3. Enforce laws and regulations  11-13         Protect residents from
    that protect health and                     exposure to contaminants
    ensure safety                               and hazardous
                                                surroundings
 4. Link people to needed         12            Implement an
    environmental health                        environmental health
    services and assure the                     program
    provision of environmental                  Manage resources and
    health services when                        develop sound
    otherwise unavailable                       organizational
                                                structures
 5. Assure a competent             1            Assess skills and
    environmental health                        capacities of
    workforce                                   environmental health
                                                workforce
                                                Provide appropriate
                                                training to build
                                                capacities in coalition
                                                building, data
                                                collection and analysis,
                                                and so forth
 6. Evaluate effectiveness,       13            Evaluate programs and
    accessibility, and quality                  develop quality
    of personal and population-                 assurance mechanisms
    based environmental health
    services
 7. Develop policies and plans    10-11         Set priorities for
    that support individual and                 environmental health
    community environmental                     action
    health efforts                              Develop plans and
                                                strategies to address
                                                environmental health
                                                priorities
 8. Mobilize community             1-3          Advocate for
    partnerships to identify                    environmental health
    and solve environmental                     improvement, build
    health problems                             constituencies, and
                                                identify community
                                                resources
 9. Inform, educate, and empower   1-13         Inform and educate the
    people about environmental                  public about
    health issues                               environmental health
                                                issues
10. Research for new insights     12-13         Select intervention and
    and innovative solutions to                 prevention activities
    environmental health                        for identified
    problems and issues                         environmental health
                                                issues
                                                Conduct process and
                                                outcomes evaluations of
                                                selected activities