Health Promotion International Advance Access originally published online on October 6, 2006
Health Promotion International 2007 22(1):80-87; doi:10.1093/heapro/dal038
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How to change environmental conditions for health
1 Hennepin County Medical Center–Mail code P1, 701 Park Avenue, Minneapolis, MN 55415, USA 2 Department of Kinesiology and Health Education, 1 University Drive, D-3700, University of Texas, Austin, TX 78712, USA 3 Faculty of Psychology, PO Box 616, 6200 MD, Maastricht, The Netherlands
Address for correspondence: Matthew J. Commers E-mail: matthew.commers{at}co.hennepin.mn.us
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SUMMARY |
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 TOP SUMMARY IntroductionEnvironmental etiology and...An Analytical Instrument for...Environmental actorsApplicationConclusionReferences |
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Since the Lalonde report, contemporary public-health theory has given steadily more attention to the role of environments in influencing health status. Environments, both social and physical, influence health directly or through complex interactions with behavior, genetics and health-care systems. They are also important for public-health because environments are the complex systems through which people are both empowered and exercise their empowerment. If public-health professionals are to play a significant role in influencing environments for health, they need analytical instruments that enable them to link specific environmental conditions with the actions necessary to improve them. These instruments must also enable public-health professionals to identify points of leverage for stimulating key actors to take the actions necessary to make environments more promoting of health. This article first presents one such analytical instrument. Then, building on examples relating to socio-economic health inequities, the analytical instrument is applied to reveal how it can add value to health professionals' effectiveness in planning interventions for more health-promoting environments.
Key words: environment; health; instrument
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Introduction |
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TOPSUMMARYIntroductionEnvironmental etiology and...An Analytical Instrument for...Environmental actorsApplicationConclusionReferences |
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Since the Lalonde report (Lalonde, 1974
), contemporary public-health theory has given steadily more attention to the role of environments in influencing health status. Environments, both social and physical, influence health directly or through complex interactions with behavior, genetics and health-care systems. Environments are also important for public-health because they are the complex systems through which people are both empowered and exercise their empowerment.
Existing literature surrounding socio-economic status and health has provided stark empirical documentation of the powerful influence that environments have upon human health (Lantz et al., 1998). Yet, there exists a tragic paradox to the literature on socio-economic health inequities. On the one hand, this literature demonstrates that we do know something of how to link social and economic environments to health status and that in a scientifically rigorous fashion. At the same time, however, it reveals our relative ignorance regarding how to influence environments to reduce those inequities. The little we do know about reducing socio-economic health inequities emanates more from common sense than scientific insight.
If public-health professionals are to play a significant role in influencing environments for health, they need analytical instruments that enable them to link specific environmental conditions with the actions necessary to improve them. These instruments must also enable public-health professionals to identify points of leverage for stimulating key actors to take the actions necessary to make environments more promoting of health. This article describes one such analytical instrument, which the authors have developed as part of their preparation for the development of a research line on strategies for influencing various aspects of physical and social environments for health.
In the following sections, we ground our discussion by defining the notion of ‘environment’, we introduce and describe the analytical instrument and we present two examples to illustrate the added value of the instrument for planning interventions designed to reduce socio-economic health inequities.
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Environmental etiology and health |
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TOPSUMMARYIntroductionEnvironmental etiology and...An Analytical Instrument for...Environmental actorsApplicationConclusionReferences |
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Environmental health etiology can be defined as the study of factors within the environment that have a causal relationship to health status. As such, environmental health etiology has a long and venerable history. All ancient cultures, including the Chinese, Indians, and Greeks, formulated specific ideas on the role of environments in influencing health and longevity. As noted earlier, the Lalonde report stimulated more explicit concern among public-health professionals for how environments influence health. Yet, if one considers the 19th century hygienists or the more recent work of authors such as McKeown (1976)
, it is clear that the Lalonde report was as much a link in a long historical chain as it was an innovation.
Environments
Requisite to any viable analytical instrument of environmental health etiology is an answer to the fascinating question of what, precisely, constitutes an environment. We base our understanding of an environment on Dubos (Dubos, 1959; Dubos, 1965) notion of the milieu externe (literally ‘external environment’). Dubos used the term milieu externe to refer to everything that exists outside of the body or mind of an individual or social group.
Under Dubos' definition, the environment, or milieu externe, includes not only the physical aspects of our surroundings. It comprises as well the social surroundings: not only other persons, but especially the symbolic aspects of social existence as communicated through language or transmitted in other ways (e.g. the meaning of a billboard advertising tobacco or portraying ideal though unrepresentative body images).
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An Analytical Instrument for Mapping Environmental Conditions, Actors and Interventions |
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TOPSUMMARYIntroductionEnvironmental etiology and...An Analytical Instrument for...Environmental actorsApplicationConclusionReferences |
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In our presentation below of an analytical instrument for environments and health, we begin where all health professionals do: at health. From there, we attempt to work up the causal chain, emerging ultimately by the role of the health professional in designing interventions for creating more health-promoting environments. The analytical instrument comprises the links between seven basic notions: health, environmental conditions, environmental actions, environmental actors, methods for intervention and empowerment. With the exception of health, we define each of these concepts and show how they contribute to the instrument as a whole.
Environmental conditions
We believe that it is useful to distinguish theoretically between the notion ‘environment’ and a condition of that environment or ‘environmental condition’. This allows us to take the important step of imagining different states of any given environment that are more or less promoting of human health. For instance, the economic environment is widely acknowledged to have a profound influence on human health. Within the broad arena of the economic environment, we might usefully distinguish between two environmental conditions: ‘greater economic equity’ and ‘lesser economic equity’. As Wilkinson (Wilkinson, 1992; Wilkinson, 1997) has shown us, the condition of greater economic equity promotes health to a greater extent than the condition of lesser economic equity.
Def1. An environmental condition is defined as a particular state of a given environment. (We intend this in much the same way that one might speak of a particular weather condition in contrast to the broad rubric ‘weather’.) In contrast to an environmental condition, we agree with Green and Kreuter's (Green and Kreuter, 2005) definition of the environment itself—consistent with Dubos' thinking as described earlier—as ‘the totality of the social, biological and physical circumstances surrounding a defined quality of life, health or behavioral goal or problem’.
Linking environmental conditions and health
There is ample evidence that environmental conditions have an influence on human health by means of at least four pathways. Figure 1 represents these pathways graphically. Our discussion below follows the numerical representations of each pathway in Figure 1.
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Pathway 1: unmediated environmental influence via health-related behavior. An environmental condition may have an influence upon our behavior, and hence our health, without the mediation of our perception and/or conscious awareness. For instance, it has been suggested that the prominence of fish in the diets of Inuit peoples is linked to good cardiovascular health. In this case, the ready availability of fish historically is an environmental condition that led to the behavior of eating in a way that seems likely to have been functional with respect to health. Some traditional health promotion and education theory and practice have taken account of this pathway (Steenhuis et al., 2004
).
Pathway 2: perception-mediated environmental influence via health-related behavior. An environmental condition may have an influence on our behavior with the mediation of our perception and/or conscious awareness. It may therefore motivate us to assume behaviors that are promoting or inhibitive of our health. For instance, we may smoke due to subjective norms or stop smoking due to our awareness of the associated health risks (Ward et al., 1997; Flay, 1999; Turner et al., 2004). Most traditional health promotion and education theory and practice have been focused on this pathway (Buchanan, 2000; Glanz et al., 2002).
Pathway 3: direct perception-mediated environmental influence. An environmental condition may cause biological changes—acute or chronic—that are significant for health as a result of our perception of that condition. For instance, an awareness that our financial security is in jeopardy is likely to lead to acute or chronic stress, which has clear implications for our immune function and cardiovascular health. Although we owe credit to many authors on stress and coping, Antonovsky (Antonovsky, 1979; Antonovsky, 1987) has been perhaps the most prominent voice in health promotion in theorizing this pathway.
Pathway 4: direct environmental influence. An environmental condition may influence our health directly without the mediation of our behavior, perception or conscious awareness. For instance, we might be injured or killed by the derailment of a train in which we are traveling or be similarly harmed in our home by a toxic gas such as radon (Field et al., 2000). This pathway has received significant attention in many fields within and outside public health, approaches which have generally been referred to as health protection.
Environmental actions
In 1943, Churchill (1943) said in a speech to the House of Commons, ‘First we shape our buildings, then they shape us’. As Churchill's quote poetically implies, it is human action—or, indeed, lack of it—that produces the environmental conditions which, in turn, influence our health. Therefore, it is also human action—or in some cases conscious lack of it—that has the capacity to produce environmental conditions that optimize our health status.
For every environmental condition, we would suggest that there exists a set of (one or more) environmental actions (Simons-Morton, Simons-Morton, Parcel and Bunker, 1988; Bartholomew, Parcel, Kok and Gottlieb, 2006) that, when taken, influence the existence or intensity of an environmental condition. In other words, these actions cause an environmental condition to exist in greater or lesser measure or to have a more or less significant influence on health outcomes.
Def2. An environmental action is therefore defined as a human action or inaction that has an influence on the existence and/or intensity of existence of an environmental condition.
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Environmental actors |
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TOPSUMMARYIntroductionEnvironmental etiology and...An Analytical Instrument for...Environmental actorsApplicationConclusionReferences |
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For each environmental action, we posit that there exists a set of (one or more) environmental actors. Environmental actors are the persons who can or do perform the environmental actions that account at least partially for existing environmental conditions. In some cases, one might conceivably identify an entire society as the set of environmental actors; in other cases, it may come down to one or more key decisionmakers.
Def3. Environmental actors are defined as the persons who can or do perform the environmental actions that account at least partially for existing environmental conditions.
Methods for intervention
As our analytical instrument implies, one potential level of intervention for public-health professionals is at the level of the environmental action itself. Public-health professionals can conceivably take actions that create or enhance those environmental conditions which they are convinced promote human health. An example of an intervention at this level is the legend of John Snow removing the handle from the Broad Street water pump and thereby sparing a London neighborhood from the further spread of cholera. Interestingly, however, aside from this example, it is actually very difficult to think of other situations where direct action upon an environmental condition by a health professional alone saves the day. Therefore, we have chosen to leave this level out of our instrument.
Yet, the instrument makes clear a second, more important level of intervention for public-health professionals. Public-health professionals also can (and often do) influence other environmental actors to take environmental actions that are favorable to the creation or enhancement of environmental conditions that promote human health. An example of an intervention at this level is the lobbying of politicians to take more assertive action in regard to the availability of tobacco or cigarettes for minors (Gottlieb et al., 2003). Whether working though key persons or organizations, or communities, however, health professionals need good strategies for leveraging their knowledge into influence over the complex processes that form the social and physical aspects of environments.
Def4. Methods for intervention are therefore defined as actions employed by public-health professionals to influence environmental actors to assume environmental actions that effect health-promoting changes in environmental conditions.
Combined instrument
Figure 2 presents the basic chain of our analytical instrument for mapping environmental conditions, actions, actors and methods for intervention. In summary, the instrument stipulates that:
- Many health outcomes (HO) are at least partially attributable to environmental conditions (EC).
- Environmental actions (EA) influence health by promoting or inhibiting environmental conditions (EC) that are promoting or inhibitive of health.
- Environmental actors (AC) are those who assume such environmental actions (EA).
- Public-health professioinals can use methods for intervention (MI) to influence environmental actors (AC) to take health-promoting health actions (EA).
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Figure 3 details another important theoretical dimension in this causal process: its multifactoral nature. As the arrows and vertical dots in Figure 3 indicate, each environmental condition may influence more than one (or any number) of different health outcomes. Similarly, each health outcome may be the product of more than one (or any number) of environmental conditions. This ‘multifactoral’ logic applies to all four sets of arrows across the five columns in Figure 3.
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Empowerment
Community and individual empowerment
Notions of community empowerment constitute an important tradition in public-health theory (Arnstein, 1969
; Wallerstein, 1992; Labonte, 1994; Wallerstein and Bernstein, 1994; Minkler, 1997; Clark, 2000; Commers, 2002; Wallerstein, 2002). This tradition has shown us that no analytical instrument of environmental health etiology would be complete without accounting for the role that communities have—and could have—in molding and sustaining the quality of their own environments.
A number of concepts of what might be broadly described as individual empowerment have also been developed in the public-health literature. These include concepts such as self-efficacy (Bandura, 1986), HARDiness (Kobasa and Maddi, 1977) and sense of coherence (Antonovsky, 1979; Antonovsky, 1987). The abovementioned constructs emphasize that individuals (or groups with shared psychological characteristics) react to the same or similar environmental stimuli differently depending both on their personal (or group) history and their ambitions for the future. Empowerment, in its essence, refers to reacting to environmental stimuli in a way that is functional with respect to the desired outcomes of those whose health or quality of life is in question. Hence, empowerment of an individual or group must have a place in any analytical instrument of environmental health etiology.
Integrating empowerment and environmental etiology
Empowerment is relevant to our instrument in at least three general ways. We describe each of these ways on the basis of the graphical representation of our complete instrument as presented in Figure 4.
- An empowered community or individual could employ a method for intervention in much the same way that a health professional would do so. The process of empowerment, from the perspective of the health professional, may therefore come down to facilitating communities' and/or individuals' ability to employ methods for intervention.
- An empowered group or individual could itself perform an environmental action. The process of empowerment may therefore encompass facilitating communities' and/or individuals' ability to undertake environmental actions directly.
- An empowered group or individual would theoretically perceive an environmental condition in ways that allow for more successful coping with (i.e. adaptation to) that environmental condition. In this sense, the process of empowerment may involve the long-term conditioning (i.e. self-learning or teaching) processes necessary to help groups and individuals perceive environmental conditions in a maximally functional way with respect to health outcomes.
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Application |
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TOPSUMMARYIntroductionEnvironmental etiology and...An Analytical Instrument for...Environmental actorsApplicationConclusionReferences |
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The complete analytical instrument of environmental health etiology and empowerment presented in Figure 4 can be employed to analyze challenges from public-health practice. Subsequently, we provide two examples of how the analytical instrument can be used. With these examples, we seek to demonstrate how our analytical instrument can be a useful tool for public-health professionals when designing interventions to improve environments for health. Because socio-economic health inequities are an issue of paramount importance to public health, we have chosen examples specifically relating to attempts to reduce such inequities. The first example pertains to what Richard et al. (Richard et al., 1996
) have identified as the ‘supranational’ level, and the second to the more localized, ‘community’ level. The examples are by necessity brief and are intended as illustrative vignettes rather than plans for action.
Health equity through debt cancellation
Interest payments on national debt by many developing nations mean that fewer financial resources are available to the national governments of those nations to finance health, welfare and other human services. In this case, within the context of our analytical instrument, health is influenced by the environmental condition of high indebtedness by national governments. Our instrument then encourages the health professional to ascertain which actions are necessary to improve the environmental condition in terms of its effect on health. At least one helpful environmental action in this case would be the institutionalization of procedures for helping reduce and cancel the debt of developing countries. The next question, according to the instrument, is who the actors are who are capable of taking this environmental action. In this case, the environmental actors are decisionmakers within the agencies, organizations and nations that have lent money to developing nations. These include wealthy nations of the northern hemisphere and organizations such as the International Monetary Fund and the World Bank. Finally, the instrument stimulates the health professional to consider what strategies, or methods for intervention, would conceivably motivate the environmental actors in question to take the necessary environmental actions to achieve the desired improvement in the environmental condition. In this case, the methods for intervention might involve the organization of jubilee campaigns to create public pressure for debt relief, the establishment of an international tax justice center, the encouragement of the creation of national departments of foreign and international development and media advocacy to assure that commitments are honored. Of course, it is important for the health professional to consider the conditions under which such methods can be applied and what the precise points of leverage are that motivate environmental actors to take desired actions.
Health equity through services to underserved communities
The availability, accessibility, price and quality of health care services constitute an important dimension in the factors that determine the health of a community. Yet, within many poorer communities, even in highly economically developed nations, health care is less available, accessible, affordable and even of lower quality than in areas with, on average, moderate or high levels of financial resources. This environmental condition contributes to health inequity between poor and middle-class people. Our instrument encourages the health professional to consider what steps must be taken to improve this environmental condition. In this case, positive environmental actions include locating health and social services in places that are easy and inexpensive to reach, making such services very affordable or free of charge and assuring that medical and social services professionals working in these areas have the training and incentives necessary to continue doing so effectively. Here, environmental actors include local politicians, such as mayors and city council members, and civil servants such as public-health and city planners and financial controllers. Our instrument then leads us to the question of how such actors can be pressured or motivated to take the necessary actions. There are a number of possible methods for intervention by the health professional. In this case, these include the publication of comparative data on care services within various cities or municipalities in the same country, research on economic efficiencies to be gained from implementing integrated care facilities, gathering models of best practice for reaching underserved populations, mobilization of the community to negotiate for health services and, if necessary, use of social action strategies to demand equitable services. Here, again, both the conditions for the methods and the determinants of actors' behavior must be examined. Further, though neither of the examples presented here documents a role for the communities whose health is in question (i.e. those served by the environmental action), these roles also need to be identified and articulated wherever and whenever possible.
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Conclusion |
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TOPSUMMARYIntroductionEnvironmental etiology and...An Analytical Instrument for...Environmental actorsApplicationConclusionReferences |
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The analytical instrument for mapping environmental conditions, actions and methods for intervention that we have described in this article is designed to assist health professionals in conducting and applying further research that links specific environmental conditions with the actions necessary to improve them. Further, we believe that the instrument can assist health professionals in identifying points of leverage for stimulating key actors to take the actions necessary to make environments more promoting of health.
In addition, we have provided two examples to show how the analytical instrument can be applied toward the important task of planning health-professional action in the interest of reducing socio-economic health inequities. Our goal in documenting the analytical instrument is to inspire and contribute to the development of a better toolkit for health professionals so that they can play a more prominent and effective role as social entrepreneurs (Duhl, 1990; de Leeuw, 1999) in influencing environments for health.
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Acknowledgement |
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The authors wish to thank Ronald Labonte, PhD, and Joop ten Dam, PhD, for contributions to the examples used in this article.
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