ERIC EJ917442: Examining the Breadth and Depth of Environmental Health through a Modified Delphi Technique

2011·0.12 MB·English

by  ERIC

Research Article
Examining the Breadth and Depth of Environmental
Health Through A Modified Delphi Technique
Dhitinut Ratnapradipa, Stephen L. Brown, and Alicia B. Wodika
AbstrAct
Background: Environmental health, a crucial part of our everyday lives, is a multidisciplinary field with many
discrepancies as to what encompasses the core areas. Purpose: This study intended to establish core areas and cor-
responding topics of environmental health as a preliminary step to identifying knowledge, attitude and behavior
questions for use in needs assessment and program planning. Methods: Fourteen to sixteen experts in various fields
of environmental health participated in a modified three-round Delphi Technique. Results: Experts established 11
core areas and 25 corresponding topic areas, and identified 443 potential questions for environmental health survey
development. Discussion: The core areas, topic areas and corresponding survey questions were produced to be ap-
plicable for people in all areas of United States. This is important for continuity within the field to have a universal
tool to measure awareness across the country. Translation to Health Education Practice: Standardizing the core
areas and specific topics of environmental health may assist practitioners in conducting thorough needs assessments
and guide program planning and research.
Ratnapradipa D, Brown SL, Wodika AB. Examining the breadth and depth of environmental health through a modified Delphi technique.
Am J Health Educ. 2011;42(1):50-57. This paper was submitted to the Journal on July 15, 2010, revised and accepted for publication on
October 22, 2010.
BACKgRoUND World Health Organization,2,4 environmen- Dhitinut Ratnapradipa is an assistant professor
Environmental health is an important tal health is defined as, in the Department of Health Education and
part of our lives and influences our daily Recreation, Southern Illinois University Carbon-
[Comprising] those aspects of human
decisions regarding work, family and nutri- dale, Pulliam Hall 307 Carbondale, IL 62901;
health, including quality of life, that
tion.1 Definitions of environmental health E-mail: [email protected]. Stephen L. Brown
are determined by physical, chemical,
vary by agency, yet most have a similar is an associate professor in the Department of
biological and social and psychosocial
undertone regarding dynamic interactions Health Education and Recreation, Southern
factors in the environment. It also refers
between humans and their environment.2 Illinois University Carbondale, Pulliam Hall
to the theory and practice of assessing,
The U.S. Department of Health and Hu- 307 Carbondale, IL 62901. Alicia B. Wodika
correcting, controlling and preventing
man Services (HHS), Environmental Health is a graduate research assistant and student,
those factors in the environment that can
Policy Committee and Risk Communica- PhD Program in the Department of Health
potentially affect adversely the health of
tion and Education Subcommittee in 1998 Education and Recreation, Southern Illinois
present and future generations.
compiled over 28 different definitions of University Carbondale, Pulliam Hall 307 Car-
environmental health.3 According to the bondale, IL 62901.
50 American Journal of Health Education — January/February 2011, Volume 42, No. 1
Dhitinut Ratnapradipa, Stephen L. Brown, and Alicia B. Wodika
In contrast to this definition, the National environmental health concerns. Their survey prior to recruitment of panel members. To
Center for Environmental Health (NCEH) included approximately “seven environmen- assure breadth and generalization, panel
defines environmental health as, “the disci- tal issues [including] air quality, water qual- members were represented from various
pline that focuses on the interrelationships ity, radiation, population growth, land use, locations throughout the United States. Ap-
between people and their environment, biodiversity and food quality,”8 however it is proximately 50% of the panel members were
promotes human health and well-being, and uncertain how they developed the content selected for the study using a cohort list from
fosters a safe and healthful environment.”3 of their survey and its entirety to the field the Environmental Public Health Leader-
To add more complexities to the matter, dif- of environmental health. Other studies by ship Institute (EPHLI). EPHLI is a one-year
ferent agencies (local, state and federal) have Dunlap and Van Liere,9 Weigel and Weigel,10 sponsorship by the CDC for 30 practicing
inconsistencies regarding the core areas and Howe,11 and Scott and Willits12 measured environmental health officials to enhance
the corresponding sub-categories or topic environmental health attitudes with a focus individual and community research.24 The
areas within environmental health. on ecological and environmental distress, remaining members were chosen from a
According to the Environmental Health not necessarily environmental health haz- diverse group of federal, state and local
Competency Project5 administered by the ards and risks. experts. Panel members were chosen for
National Center for Environmental Health, this project on the basis of formal training,
the Centers for Disease Control and Pre- pURpoSE practice and leadership in the field of envi-
vention (CDC), and the American Public because environmental health is such ronmental health. According to De Villiers et
Health Association (APHA), environmental a broad field, encompassing nearly every al.,16 a Delphi technique expert is character-
health can include 23 areas including ambi- aspect of daily life from air to water to food ized by possessing knowledge and experience
ent and indoor air quality, water pollution, to the chemicals in the products we use, applicable to the field of study,14,18,19,22 while
safe drinking water, radiation, food safety, this study strove to create a standardized also encompassing the reverence of their
bioterrorism, vector and pesticide control, list of the core areas and underlying topics colleagues. Panel members varied in their
and healthy housing to list a few. Although within each area to facilitate discussion, educational experiences, number of years
this list includes many well-established areas future research and program development of post-secondary education, locality of
of environmental health, other agencies’ lists and implementation. In addition, this employment and number of years in the
of core areas may differ depending on the lo- study is intended as a preliminary step to field (Table 2). The number of participants
cality of the environmental health program/ identify knowledge, attitude and behavior needed to complete Delphi rounds is am-
department. For example, in the Guidebook questions for use in needs assessment and biguously described in literature. A study de-
for Local Health Officials jointly created by program planning. picting Delphi research procedures reported
the National Association of County and City The Delphi Technique was first used in as few as 10 individuals to as many as 1,685
Health Officials (NACCHO) and NCEH,6 the 1950s13-16 to acquire the thoughts and is sufficient to participate;25,26 whereas other
18 areas of environmental health were listed opinions of specialists methodically13,15,17-19 studies have described 15-60 participants is
including motor vehicle accidents, loss of in a particular field. Presented by the RAND adequate.20,27,28 Exactly 20 experts were con-
biodiversity, violence, AIDS and natural Corporation,17 the technique concentrates tacted and 18 agreed to participate (N=18),
disasters. While NACCHO’s list had over- on a main problem or theme. Named af- but only 16 panel members completed
lapping core areas with the CDC’s, there ter the Greek oracle that predicted future round one, thus reducing the number for
were also contradictions between their events,13,14,16,19,21,22 the technique has specific future rounds. For purposes of this study,
lists. The HHS’s Healthy People 2010 had six guidelines including anonymity of expert the terms “panel member” and “expert” are
environmental health objectives including participants13,17,23 and expert reasoning to synonymous.
outdoor air quality, water quality, toxics and the centered problem,17 while using ques- Panel Member Communication
tionnaires or survey-based methods to
waste, healthy homes and healthy commu- Panel member anonymity was vital to
obtain responses. For this study, a modified
nities, infrastructure and surveillance, and this study. To reduce any biases and com-
technique was used to identify the core areas
global environmental health; with a total munication regarding the material, experts’
of environmental health as well as their cor-
of 30 sub-categories under the objectives.7 names were not disclosed nor were the
responding topics for practical use in many
Due to the inconsistencies of the current number of members within the group. Com-
diverse types of programs.
listings for the core areas of environmental munication was through blind-copy email
health (Table 1), a standardized listing of the instead of conventional mailing methods,
METHoDS
core areas is needed for future research and and experts were only contacted when a new
program implementation. Recruitment round was initiated or to update the status
Tempte and McCall8 predicted patient Human Subjects Committee Institution- of a pending round. Panel members were
environmental health attitudes addressing al Review board (IRb) approved this project invited to email questions about the project,
American Journal of Health Education — January/February 2011, Volume 42, No. 1 51
Dhitinut Ratnapradipa, Stephen L. Brown, and Alicia B. Wodika
Table 1. Comparison of Environmental Health Core Areas
Environmental Department of Health and
Health Research Environmental Health Human Services (DHHS): NACCHO & NCEH Guidebook for
Group (2009)1 Competency Project (2001) Healthy People (2000) Local Health Officials (2000)
Core Area Similarities
Ambient Air Quality Ambient (outdoor) Air Pollution
Air Outdoor Air Quality
Indoor Air Quality Indoor Air Pollution
Safe Drinking Water
Water Water Quality Drinking Water Quality
Radiation Radiation
Food Safety Food Safety Food Safety
Emergency
Disaster Planning and Response
Preparedness
Healthy Housing Healthy Housing Healthy Homes
Infectious disease Infectious Diseases
Vector and Pesticide Control
and Vector Control Pesticides
Toxicology Toxic Chemical Control Toxics and Waste
Injury Prevention Unintentional Injury
Waste and
Solid Waste Management Hazardous Waste Disposal
Sanitation
Weather and Global Health Issues Global Environmental Water Pollution
Climate Change Water Pollution Control Health Global Climate Change
Core Area Differences
Noise Pollution Infrastructure and AIDS
Industrial Hygiene Surveillance Overpopulation
Childhood Lead Poisoning Radon
Acid Deposition Depletion of Natural Resources
Cross Connection Elimination Motor Vehicle Accidents
Institutional Environmental Loss of Biodiversity
Control Natural Disasters
Recreational Area Environ- Use/Abuse of Alcohol and Con-
mental Control trolled Substances
On-Site Liquid Waste Disposal Violence
Bioterrorism
11 23 6 18
1based on results from Delphi round one
but if they had specific questions regarding mented to reduce any biases by indirectly Determining Consensus
the content or instructions of a particular assisting a panel member in filling out the Presenting simple statistics including
round, they were instructed to complete as survey by answering questions regarding a mean and median values15 representing
much as they understood. This was imple- specific round. consensus among panel members is an
52 American Journal of Health Education — January/February 2011, Volume 42, No. 1
Dhitinut Ratnapradipa, Stephen L. Brown, and Alicia B. Wodika
Table 2. panel Member Demographics
Total Panel Members
(N = 12)1 % Panel Members
Degree Master of Science Degree 1 8.3%
Doctoral Degree 7 58%
Professional (MPA, MPH, MD, PharmD) 4 33%
# Years Post-Second- 1-6 5 41.6%
ary Education 7-12 5 41.6%
13-16 2 16.6%
Number of years 5-10 3 25%
experience 11-15 0 0
16-20 1 8.3%
21-25 3 25%
26-30 4 33%
31 and up 1 8.3%
Specialty2 Air Quality 1 8.3%
Asthma 1 8.3%
Climatology 1 8.3%
Drinking Water 1 8.3%
Emergency Preparedness 1 8.3%
Epidemiology 1 8.3%
Food Safety 2 16.6%
Hazardous Materials 2 16.6%
Health Housing 4 33%
Injury Prevention 1 8.3%
Lead Poisoning 3 25%
Pest Management and Surveillance 1 8.3%
Public Health 1 8.3%
Radiation 1 8.3%
Recycling 1 8.3%
Risk Assessment 1 8.3%
Solid Waste 1 8.3%
Toxicology 3 25%
Waste Water 1 8.3%
Water Quality 3 25%
Type of Employee Academia 2 16.6%
Local Government 2 16.6%
State Government 4 33%
Federal Government 3 25%
Private Sector 1 8.3%
1 based on 12 out of 16 panel members who completed demographic information
2 Does not add to 12 panel members, due to possibility of more than one specialty
important aspect of the technique with the the first round16 and at least 51% in all In general however, consensus was reached
ultimate goal of acceptance of a proposed rounds.16,18 Due to the variability among if panel members had agreed entirely on
topic with little variance.14,16 Previous stud- the Delphi rounds, consensus among a particular topic, or had at least 60%
ies have used varying numbers of responses the panelists oscillated depending on the (10 out of 16 panel members) agreement
to achieve consensus including 70% in specificity of the content within the round. among experts.
American Journal of Health Education — January/February 2011, Volume 42, No. 1 53
Dhitinut Ratnapradipa, Stephen L. Brown, and Alicia B. Wodika
Delphi Round One (labeled as important/very important), at Panel members were each sent a cover
For the first round, it was important to least 10 panel members agreeing it was an letter containing information regarding the
establish the core areas of environmental “important” topic, and having an average third round and the corresponding link to
health. To accomplish this, 18 panel mem- consensus of greater than 3.5 out of 5. Ex- their assigned survey. It was only necessary
bers were sent a cover letter expressing grati- perts were given one week to finish Delphi that each panel member complete one
tude for agreeing to assist with the project, round two, estimated to take approximately survey; however, if panel members wished
as well as two other attachments: a project 30-35 minutes to complete. A reminder to complete extra surveys, they were sent
overview containing goals and objectives, email was sent one week after the deadline additional links to the other sections. It was
and the Delphi round one form. based on to any remaining panel members who estimated that panel members would take
an open-ended limitless question, panel did not complete the second round. They approximately 30-40 minutes to complete
members listed what they believed were were asked to complete it at their earliest Delphi round three. Due to the length
the core areas of environmental health. A convenience or request an extension for and dedication required for the third and
comments section was also added in case completion if needed. final round, panel members were given
panel members wished to express other Delphi Round Three approximately three weeks to respond.
ideas, thoughts, or questions regarding the Consensus among panel members was set
This round involved the compilation of
project or first round. Experts had one week at 50% agreement.
knowledge, attitude and behavior questions
to complete the first round. Depending on
from each topic area identified in the second
the depth of the answers, the first round was RESUlTS
round. Due to the labor-intensive task of
estimated to take approximately 15 minutes
survey question development, the research Delphi Round One
to complete.
team developed potential survey questions From the original list of 18 experts who
Delphi Round Two for the panel members to identify as suitable agreed to participate, 16 returned round
The results of round one were used as for a consumer survey. Utilizing various one, with a response rate of 88%. based on
a basis for impending Delphi rounds. The resources including CDC literature and en- the responses from the first Delphi round,
goal of the second round was to identify key vironmental health textbooks, the research 27 core areas were provided with some
topics within each core area. Using Delphi team identified 576 questions for the panel responses overlapping. From the core areas
round one as a template for the second members to analyze for appropriateness in developed in round one, the research team
round, the research team compiled 177 po- a survey. Developing these questions was compiled the most commonly reported
tential environmental health topics for panel an enormous task that required planning responses into the core areas used for the
member evaluation. SurveyGizmo version and categorization of questions that rep- remainder of the study. It was the discre-
2.6.14929 an online survey tool, was used to resented topic areas which corresponded tion of the research group to compile core
collect responses during the second round. to the core areas. Each topic area needed at areas if felt they were overlapping. Core
Panel members were asked to rate topics least 3-5 knowledge, attitude and behavior areas with fewer than two supporting
within core areas that would be the best questions in order to achieve acceptable experts were discarded from the project.
gauge of an individual’s overall awareness reliability for the final survey instrument. The research team identified the most
of environmental health issues. To minimize potential panel member drop- commonly reported core areas as well as
A Likert-type style scale (“very unim- out due to respondent fatigue, the research areas that could have been combined to
portant,” “unimportant,” “neutral,” “im- team decided to divide the survey tool into be one area. This included the combina-
portant,” “very important,” “not sure”) was five separate instruments (sections A, b, tion of recreational safety, poison control
used by the panel members to answer survey C, D and E) thereby setting the maximum and injury/violence prevention into one
questions. If there was a topic the experts number of review questions at 115 or less area of injury prevention, coalescing waste
believed should have been included within per instrument. Each instrument contained management and sanitation, and finally
a particular category but was not present five different topic areas; instruments were building/hazardous materials and pest
within round two, they were asked to list assigned to specific panel members based on control into toxicology. After compiling
the topic in the designated “comments” sec- their area of expertise within environmental the responses from round one, 11 core
tion and determine it if was “important” or health. Panel members were to respond to areas of environmental health were identi-
“very important.” At the end of the survey each question by selecting one of four op- fied for consumer/public awareness (Table
document, there was a questions/comments tions: “the public already knows this ques- 1). The most common answers provided
section for the entire survey document. The tion,” “the public should know this question, by the panel members were “air,” “water,”
following protocol was used to determine but most of them do not know,” “it is not “toxicology” and “food.” The following
consensus among panel members’ responses: necessary for the public to know this,” and core areas were identified by one or more
at least 66% agreement on a particular topic “do not know.” panel members but were excluded from
54 American Journal of Health Education — January/February 2011, Volume 42, No. 1
Dhitinut Ratnapradipa, Stephen L. Brown, and Alicia B. Wodika
the final list of 11 core areas because they
Table 3. Summation of Delphi Rounds Two and Three
did not meet the research team’s consensus
criteria: soil, geology, biology, population
Topic Areas Total Survey Questions
density, promotion of safe workplaces and
(Delphi Round Two) (Delphi Round Three)
safe industrial hygiene.
Smoking and Second hand smoke 15
Delphi Round Two
Carbon Monoxide 21
The next round decided what topics were
General Air Quality 9
important within the 11 specific core areas.
Asthma 18
Fifteen panelists returned completed on- Radon 19
line surveys; creating an 83% response rate Mold 10
(15/18 members). Surveys were tabulated
Water Sources 18
and scores for each topic area were aver-
Drinking Water 23
aged for an overall consensus. Following the
Water Usage 13
general protocol, 33 topic areas (47%) from
Waste Water 19
the original list of 70 topics, were removed.
General Weather and Climate Change 26
The remaining 37 topics were condensed by
their topic themes to yield 25 areas (Table Food Preparation and Storage 38
2). Comments in the second round were Food Supply 27
geared towards providing the correct plac- General Healthy Housing 27
ing of topic areas and providing additional
Recycling 19
environmental health concepts not included
Garbage and Disposal 8
in our original listing. These included items
Integrated Pest Management 16
such as radon, ozone, air fresheners and
Communicable Disease 15
colognes in the air category; personal hy-
giene in food handling, frequency of eating General Radiation 20
raw foods and hormone usage in animal General Injury Prevention 9
products in the food safety topic area; and
General Emergency Preparedness 10
industrial radiation exposures and protect-
Heavy Metals 24
ing children from severe burns in the radia-
Pesticides 22
tion category.
General Toxicology 7
Delphi Round Three Drugs 10
The third round identified appropriate
25 Topic Areas 443 Questions
questions for the survey instrument. Four-
teen panel members returned completed
surveys for round three, resulting in a 77% DiSCUSSioN the commonalities of the round responses,
response rate (14/18 members). Four panel Understanding public health topics can but also kept core areas (i.e. weather and
members completed extra surveys, with affect important decisions made by consum- climate change/emergency preparedness)
two members completing three and two ers including the interpretation of health that were not widely agreed upon by the
members completing two surveys total. risks, political and environmental issues, and experts as being the main core areas of en-
questions were analyzed in the category deciphering biases in media-reported health vironmental health.
“public should know this, but most do not,” information.30,31 Environmental health has As depicted in Table 1, there was overlap
with consensus set at 66% agreement among shifted from traditional categories such as with the core areas developed in this study
panel members. Out of 576 total questions food safety, communicable disease, water with the core areas delineated in other sourc-
that were analyzed, the results of this round quality and air quality to also comprise es [Environmental Health Competency Proj-
removed 133 questions for a remaining total more emerging categories including “nuclear ect, 5 HHS: Healthy People,7 and NACCHO
of 443 knowledge, attitude, and behavior power, war and terrorism, global climate and NCEH Guidebook for Local Health Of-
questions (Table 3). Comments from the change and energy resources.”32 To ensure ficials6]. However, the agencies listed several
third round comprised their categorizing of both emerging and traditional areas of en- areas of environmental health (AIDS, loss of
questions, suggesting the addition of ques- vironmental health were represented in the biodiversity, natural disasters, on-site, liquid
tions and clarity. survey, the research team not only assessed waste disposal and bioterrorism) that were
American Journal of Health Education — January/February 2011, Volume 42, No. 1 55
Dhitinut Ratnapradipa, Stephen L. Brown, and Alicia B. Wodika
not included within our study. In regards SurveyGizmo, to administer Delphi rounds declining response rates between rounds
to the traditional vs. emerging components two and three. This proved to not only be (16 to15 to14), we were able to maintain
of environmental health, a majority of the excellent for data collection, but also for the critical mass of opinions necessary to
agencies had many traditional areas of en- the creation of the survey document and complete the project.
vironmental health with only one including was practical for all panel members to eas-
global climate change. Several of the agencies ily access. TRANSlATioN To HEAlTH
decided to have multiple core areas with The core areas, topic areas and corre- EDUCATioN pRACTiCE
similar themes including The Environmental sponding survey questions were produced As one of the seven core areas of re-
Health Competency Project5 which had two to be applicable for people in all areas of sponsibility for Certified Health Education
categories for “air” including ambient and the United States. Plans for future research Specialists,33 conducting a needs assessment,
indoor air quality. This study chose to have include implementation of focus groups is a fundamental aspect of program plan-
those categories combined to one specific to narrow down the number of identified ning. A standardized list of core areas and
core area of “air.” This was also similar for survey questions for practical use by con- specific topics for consideration may assist
other categories including infectious disease sumers and to clarify any questions that practitioners in conducting thorough envi-
and vector control and water. are ambiguous and may be misunderstood. ronmental health needs assessment. In ad-
Throughout each Delphi round, it was Having a standardized instrument to mea- dition, the specific knowledge, attitude and
important to receive comments from panel sure knowledge, attitudes and behavior behavior questions may serve as the basis for
members regarding not only the content of of consumers will allow for a better un- future development of a standardized survey
the round, but also concerning suggestions derstanding of public and environmental tool. Use of a standardized instrument for
for future studies. Regarding the construc- health, while isolating localities deficient in measuring the knowledge, attitudes and
tion of core areas, a panel member stated “I environmental health literacy. behaviors of the general public, regardless
find it hard to not see an environmental con- Limitations of their geographic location, will allow state
nection to just about everything;” whereas, Although this study was able to success- and local health departments to search for
another panel member stated “environ- fully obtain the core components of environ- weaknesses within specific localities and
mental health focuses on all aspects of these mental health, it would have been beneficial plan targeted interventions. This is especially
major areas including scientific investigation to include a Delphi round that encompassed important to increase community awareness
and development of policy to mitigate nega- a qualitative aspect from the experts. Each and outreach and for assessing the behaviors
tive health consequences.” Another panel round had a qualitative component for feed- practiced by various communities. Isolating
member stated, “rather than considering any back, especially the first round where partici- areas with decreased environmental health
single core area independently, it is impor- pants listed what they believed were the core literacy will assist the practitioner to ef-
tant to realize that many of the disciplines of areas of environmental health. However, fectively plan and prepare to better educate
environmental health are intertwined both this could have been enhanced by perhaps individuals on the importance of environ-
within and outside core areas.” Understand- asking them to list what they believed were mental health.
ing the perspective of the experts provides the core areas along with why they thought
insight into the difficulties in selecting the they were important in the field. In round ACKNoWlEDgEMENT
core areas and topic areas that encompass the one, it also may have been important to ask This research project was funded by the
broad field of environmental health. Delphi the panel members to identify each of their Office of Research and Development Ad-
rounds one and two were intense rounds that listed core areas as emerging or traditional. ministration, Southern Illinois University
intricately involved developing and selecting It was significant however, for the responses Carbondale. The authors would like to thank
practical core areas that would not be limited of the first round to be completely developed the experts who participated in the Delphi
by geographical location. by the experts themselves and not lead any rounds for their time and insights.
This study developed core areas similar of their answers.
to Tempte and McCall’s study on environ- Another limitation to this study was the REFERENCES
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