The World Hea lth Organization is a spec ialized agency of the United Nations with primary responsibility for internati onal hea lth matters and publi c hea lth . Through thi s Orga ni za ti on, whi ch was created in 1948, th e hea lth profess ions of over 190 co untri es exc hange the ir knowledge and ex peri ence with the a im of maki ng possible th e at tainment by all c iti ze ns of th e world of a leve l of hea lth th at will permit them to lead a soc iall y and econom ica ll y producti ve life.
The WHO Reg ional Office for Europe is one o f six regional of fices throughout the world, each with its ow n programme geared to the parti cular hea lth problems of the countri es it se rves . The Euro pean Reg ion embraces so me 870 million people li ving in an area stretching from Greenl and in the north and the Med iterranea n in the south to the Pac i fie shores of the Ru ss ian Federat ion. The Europea n progra mme of WHO therefo re co ncentrates both on th e problems assoc iated with industri a l and post-industrial soc iety and on th ose faced by th e emerging democracies of central and eastern Europe and the former USS R. In its strategy fo r attaining the goa l of hea lth for all the Reg ional Office is ar rangin g it s ac ti viti es in three main a rea s: lifestyles co nduci ve to hea lth , a hea lthy environm ent, and appropri ate serv ices fo r prevention, treatment and ca re.
The Europea n Reg ion is characte ri zed by th e large number of languages spoken by it s peo pl es, and the resulting difficulties in di sseminat ing in fo rm ati on to a ll who may need it. App li cat ions for ri ghts of tran slat ion of Reg iona l Office books arc th erefore mos t we lcome.
Environmental health services in Europe 4
Guidance on the developn1ent of educational and training curricula
WHO Library Cataloguing in Publication Data
Fitzpatrick, Martin Environmental health services in Europe 4 / by Martin Fitzpatrick and Xavier Bonnefoy
(WHO regional publications. European series ; No . 84)
I .Environmental health 2.Health services - organization 3.Europe I.Bonnefoy, Xavier II.Title Ill.Series
ISBN 92 890 1350 8 ISSN 0378-2255
Text editing: Frank Theakston
LM Classification: WA 30)
Cover design: Axiom Design, London, United Kingdom
Wo~ld Healt~ Organization lfi.f ~ Regional Office for Europe ~ • 1
Copenhagen ~
Environmental health services in
Europe 4 Guidance on the development
of educational and training curricula
Martin Fitzpatrick and Xavier Bonnefoy
WHO Regional Publications, European Series, No. 84
ISB 92 890 I 350 8 ISSN 0378-2255
The Regional Office for Europe of the World Health Organization wel comes requests for permission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Publications unit, WHO Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen 0, Denmark, which will be glad to provide the latest information on any changes made to the text, plans for new edi tions, and reprints and translations already available.
© World Health Organization 1999
Publications of the World Health Organization enjoy copyright protec tion in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved.
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concern ing the legal status of any country, territory, city or area or of its authori ties, or concerning the delimitation of its frontiers or boundaries. The names of countries or areas used in this publication are those that ob tained at the time the original language edition of the book was pre pared.
The mention of speci fie companies or of certain manufacturers' prod ucts does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
The views expressed in this publication are those of the authors and do not necessarily represent the decisions or the stated policy of the World Health Organization.
PRI NTED IN D ENMARK
Contents
Page
Foreword ............. .............. .. ..... ....... ........................................... ... .. v 11
Introduction ........ ..... .... ........ ........................ ............... ............. ... .... .
I . Lea rning obj ec ti ves............................ ......... ............ ..... ...... .. ... . 19
2. Approaches and methodolog ies for teaching environmental hea lth ............ ....................... ... ......... ................ . 53
3. Eva luating systems in educati onal programmes.. .......... ...... . 65
4 . Proposed curricul a fo r environmental hea lth profess iona ls... ................................. .. ... ..... .. .... .. ... ............ ..... ... 75
References . .. .... .. .. .. ... .. .. .. . ... .. .. .. .. ...... . ... .. ..... .. .. .. .. ... . .. .. .. .... ... .. . .. .. .. . 8 5
Annex I. Deta il ed curriculum fo r environmental hea lth technici ans/a ides ......... ................. .. .. ..... ................... .... 89
Annex 2. Detail ed curri culum fo r ge neral technici ans/a ides .... I 05
Annex 3. Deta il ed curri culum fo r speciali st environmental health profess ionals .... .......... ....... .. .... ..... ...... ............ .... I 15
Annex 4. Detailed curri culum fo r other speciali st profess ionals .. .. .. .... .... .. ..... ..... .. ... .. .... .. ... .. ... .. ... ... .... ... .. . 13 7
Annex 5. Detailed curriculum for environmental health se rvice ma nagers .......................................................... 155
Annex 6. Proposed curriculum for managers of other sectors ............................................................. I 6 7
Annex 7. Guidelines for developing and evaluating learning objectives for educational programmes in environmental health .... ...... ... ......... .... ... ..... .. .... ....... 177
Annex 8. Participants in preparatory meetings, 1995- 1996· .... 183
Foreword
Th e Third European Conference on Environment and Health , to be held in London in Jun e I 999, will provide a lime fv opportunity to review the progress of the Member Slates of the WHO European Re gion in developing their environmental health services. Th eir com mitment to this process of developmenl stretches back over the last two decades through the European regional policy for hea lth for all. This was followed up by the First European Conference on Envi ronment and Health , held in Frankfurt-am-Main in 1989, which iden t(fied th e groundbreaking principles underpinning environmental health in the European Charter on Environment and Health .
Five years later, the Second European Co,~ference in Helsinki presented a clear path forward that all Member States could follow, through th e developm ent of national environmental hea lth action plans (NEHAPs). in response to requests from countries fo r support in developing and implementing NEHA Ps. the Regional Ofjice set up a project to produce a series of publications dealing with all aspects of environmental health services management. The produc tion of these publications has involved environmental health profes sional and institutions, international agencies, and not least the coun tries themselves. The first in the series provided an overview of how services are managed throughout the Region , and the second dealt with the variety of policy options that Member States might consider in organizing those services. Th e third publication in the series con centrated on the staffi"ng of environmental health services.
vii
viii ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
This fourth hook provides practical ass istance in the education and training of environ111ent and health professionals. This includes identify ing relevant learning objectives, developing appropriate teaching 111 eth odolog ies, and proposing a range of curricula for l'arious levels of professional. Th ere was tremendous interest on the part of Me111ber States and educational institutes in the development of this publication. Th e result is a book that is grounded in the real ities of Member States who are endeavouring to equip their environ ment and health professionals to deal with the rapid~y changing world in which the_v work. It also allempts lo facilitate environment and health service providers and educational institutions in developing a common understanding of how to address the needs of these pro fessionals.
Th e produ ction of this .fourth book in volved lengthv discussion and wide-ranging debate among the many professionals and insti tutions consulted during its preparation. Th eir commitment, knowl edge and experience \\'ere instrumental in bringing this work lo .frui tion . Th e preparation of the hook also provided a .forum .for a ve1y diverse range of people .from many countries to 111 eet toge ther and share their experiences.
I should like to thank Martin Fitzpatrick, on secondment to the Environment and Health Departm ent al the Regional Office. Th e many consultants and advisers involved must also be thanked .for the unstinting contribution of their time and talent. Finally, the sup port of the Department of Health and the Eastern Health Board of Ireland is warmly acknowledged.
J.E. Asvall WHO Regional Director .for Europe
Introduction
This book is intended to serve as a practical guide to the develop ment of relevant curricula for the education and training of envi ronmental health professionals. The range ofrelevant professionals, iden tified in a companion volume{/) , are addressed in further detail below.
In particular, this book aims to:
I. set out principles for developing policies on education and training for environmental health professionals at national and subnational levels;
2. formulate proposals for cun-icula that aid in conferring the nec essary competences to environmental health professionals;
3. support the upgrading of national capacities for education and training to facilitate national self-reliance in the prevention and control of environmental hazards; and
4. promote the harmonization of international efforts to upgrade the environmental health workforce in Europe.
This Introduction provides an overview of the development of environmental health within the WHO European Region, and discusses various difficulties being faced by environmental health services. Some of these problems may be tackled by improving the
2 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
competence and professional capacity of those working in environmental health services. A number of the concepts and principles that underpin this competence and professional capacity have been developed through a range of international agreements. Identification of these professionals is an important step in address ing these problems. The results of survey work carried out by WHO on this issue are presented and a model of the manner in which these professionals become involved in the area of environmental health is proposed . Finally, a brief overview is presented of the process and components of developing an educational programme.
Chapter I deal s with the development of learning objectives, which basically set out those things that students should be able to do at the end of an educational programme that they could not do before. Developing relevant and achievable learning objectives is an essential element of any educational programme. For environ mental health professionals, the overall objective is to support them in developing competence in their relevant field of study and even tually in their work. This concept of competence is discussed and relevant learning objectives are placed in the context of the objec tives, functions , activities and tasks carried out by environmental health services in particular areas of concern.
In Chapter 2, the various approaches and methodologies for teach ing environmental health are discussed. These include a description of some of the available teaching resources , as well as the locations and opportunities that exist for carrying out educational programmes for environmental health professionals. The range of appropriate approaches and methodologies available and their comparative ad vantages and disadvantages are also reviewed.
The evaluation of educational progra mmes has received particu lar attention in many quarters in recent years. In Chapter 3, the need for evaluation of educational programmes is discussed and a range of guide lines for evaluating various components of a programme are proposed. This process of evaluation is vital in ensuring the relevance of educa tiona l programmes offered to environmental health professionals.
In Chapter 4, curricula for various environmental health profes s ionals are proposed. These curricula are based on the model of
INTRODUCTION 3
environmental health professionals presented in the Introduction, and are intended to form a template that may be adapted as neces sary to suit national needs and those specific to different disciplines.
Annexes A- F deal with the modular details of these curricula, whi le Annex G provides guidelines for the development and evalu ation of learning objectives for environmental health education pro grammes.
The target audience of this book includes: governments of Mem ber States; subnational and local government authorities; educational authorities and institutions; private sector employers; economic sec tor employers; environmental health professionals; professional rep resentative groups; and other nongovernmental organizations.
TRAINING OF ENVIRONMENTAL HEALTH PROFESSIONALS
Many Member States in the WHO European Region have experi enced profound change over the past IO years. These have included, on the one hand, the break-up of the former USSR and the emer gence of a greatly enlarged family of Member States. On the other hand, there has been a concerted drive by many countries (particu larly in the context of the European Union) towards greater political and economic integration. For all Member States it has been a pe riod of re-evaluating old a lli ances, forging new ties, and coming to terms with a wide variety of new circumstances. One result is that in some Member States, the institutions of state and the personnel who staff them are insufficiently equipped in terms of resources and com petence to tackle successfully the many serious environmental health challenges that now confront them.
This situation was highlighted by a major survey of environmen tal hea lth services carried out by WHO during 1993 and 1994, in the course of producing the first two publications in the series (2,3) . This survey also made it c lear that the personnel employed by the environmental health services in a number of countries are strug gling to deal with the effects of the socioeconomic changes cur rently taking place. The processes of decentralizing authority and building market economies require that environmental health services
4 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
management capacities be considerably improved. There are also very great challenges facing all Member States in relation to dealing with transboundary environmental health issues, the role of the pri vate sector in environmental health services, and increased po litical and economic integration within the Region.
In view of these challenges, there is a need for Member States to evaluate critically the relevance and quality of education and train ing being provided to students who will pursue careers in environ mental health , as well as to address the needs of professionals cur rently working in the field. The cornerstone of such an exercise must be the range and quality of education and training programmes of fered throughout the Region .
BACKGROUND TO DEVELOPMENTS IN ENVIRONMENTAL
HEALTH
The following is a very brief synopsis of the developments that have taken place in the field of environmental health in the European Region in recent years.
• In 1980, the European Member States adopted a common strat egy for achieving health for all. This strategy focused on four main issues: lifestyles and health , health and environment, reorientation of health care systems, and mobilization of sup port to bring about necessary change . The main concepts un derpinning this strategy are dealt with in more detail later in this book.
• In 1984, the Member States adopted 38 regional targets address ing these issues (4) , and these were revised in 1991 (5) . Nine of the targets are directly concerned with environmental health.
• In 1987, the report of the United Nations World Commission on Environment and Development, Our common fi1ture (6) advocated that human activities should follow a path of sus tainable development, which it defined as development that meets the needs of the present without compromising the ability of future generations to meet their own needs.
INTRODUCTION 5
• In 1989, the Regional Office organized the First European Conference on Environment and Health in Frankfurt-am-Main, bringing together for the first time ministers of environment and of health from 29 Member States. The Conference adopted the European Charter on Environment and Health (7), which represents a major step forward in the development of joint public health and environmental policies.
• In 1992, the United Nations Conference on Environment and Development, held in Rio de Janeiro, brought together repre sentatives from 179 countries, as well as governmental and nongovernmental organizations. In preparation for the Con ference , the WHO Commission on Health and Environment produced a report (8) providing a comprehensive review of the world health situation in regard to environment and devel opment. The Conference endorsed Agenda 21 (9), a blueprint for socia ll y, economically and environmentally sustainable development for the next century.
• Also in 1992, the European Community adopted its Fifth En vironmental Health Action Programme (JO), which is now the European Union's central tool for implementing Agenda 21 within its functional area. The Programme is currently being revised and updated.
• In 1993, in response to the Rio Conference, WHO adopted a new g lobal strategy for health and environment (I/). In the same year, in parallel initiatives by other United Na tions agencies, a broadly integrating process through the ministers of environment was forged in the Lucerne Decla ration (J 2).
• In 1994, The Second European Ministerial Conference on En vironment and Health, in Helsinki (J 3), identified the frame work for developing national environmental health action plans (NEHAPs). The ministers of environment and of health a lso ca ll ed for the Regional Office to work in conjunction with other partners on developing the necessary mechanisms and guidance to assist countries in the development of environ mental health services (14).
6 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
THE HELSINKI CONFERENCE AND THE ENVIRONMENTAL HEALTH ACTION PLAN FOR EUROPE
The framework for developing NEHAPs is described in detai l in the Environmental Health Action Plan for Europe ( 14) , as endorsed by the Helsinki Conference in 1994. The key issues identified by the Action Plan include the need to support and strengthen environ mental heath services and to develop, through appropriate educa tion and training, a cadre of environmental health professionals able to manage and facilitate the implementation of structured programmes for the protection of environmental health.
With respect to education and training, the objective is "to pro vide education and training at all levels so as to create cadres and teams of environmental health professionals who will be responsi ble for implementing and managing specific programmes to improve environmental health" .
The objectives relating to public information and health educa tion include "(Ensuring and enhancing) participation of the public at the earliest stage in environmental health planning, priority-set ting and programme implementation based on the principle of open ness and equal partnership of all involved".
THE WHO FOLLOW-UP TO THE HELSINKI CONFERENCE
The Regional Office has had an active programme on environmen tal health services in the Region for some years. To further develop the work carried out to date, and in accordance with its mandate from Helsinki , WHO has been developing a range of other initia tives. At a consultative meeting of Member States held in Vilnius in November 1994 (15) to discuss the follow-up to the Helsinki Con ference, a number of project proposals were presented to the Mem ber States for their endorsement. One such proposal concerned staff ing, professional education and training for environmental health services.
The scope and purpose of the proposed project adopted by the Member States in Vilnius was " to build and strengthen the capacities
INTRODUCTION 7
of environmenta l health services, by improving the knowledge of the exist ing situation regarding the staffing of environmental health services a nd the education and training of environmental health professionals" (} 5). The proposed products from the project include guidance documents dealing with the staffing of environmenta l health serv ices 1n the European Region ( / ) and on the development of educati ona l and training curricu la for environmental health profes s iona ls.
DEFINING ENVIRONMENTAL HEALTH
With such a wide array of professionals involved in environmental hea lth, it is obvious that the term holds a variety of meanings and connotations throughout the European Region. In many countries the concept of env ironmental health has been developed over many yea rs and is we ll established, while in others the term is relatively new, and its conceptual development with regard to the national situation is sti ll evo lv ing. In stil l other Member States, because of hi storica l, political , cu ltural and linguistic factors, the conceptual eq ui va lent for the term simp ly does not exist, and environmental health issues are approached from very different viewpoints. As a resu lt of consultations organized by the Regional Office in Sofia in October 1993 ( /6) and in Vilnius in November 1994 (/5), a new definition of e nvironmental health emerged:
Environmenta l health comprises those aspects of human health, including quality of life, that are determined by physical, chemical biological, social and psychosocial factors in the environment. It also refers to the theory and practice of assessing, correcting and preventing those factors in the envi ronment that can potentially affect adversely the health of present and future generations.
This definition articulates the desire of Member States in the Eu ropean Region that environmenta l health should embrace quality of life , psychosocial factors and sustainable development.
These consultations a lso addressed the definition of "enviro n mental health services". Even a c ursory review of this issue will revea l the heterogeneous nature of the inst ituti ons at local, regional and nationa l leve ls that deliver environmenta l health services in the
8 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
countri es of the Europea n Region. The dive rs ity that ex ists in re la tion to the interpretation of environmenta l hea lth is equa lly applica bl e to environme nta l hea lth services. One defi niti on that has been proposed as a result o f these consultati ons is:
Environmental hea lth services are those services which implement envi ronmental hea lth policies th rough monitoring and control acti vities. They also carry out that ro le by promoting the improvement of environmental parameters and by encouraging the use of environmentally fr iend ly and hea lthy technologies and behav iours. T hey also have a lead ing ro le in developing and suggesting new policy areas.
In the fin a l ana lys is, it is the prerogati ve of Me mbe r States to dec ide the kinds of in stituti ons they w ish to deve lop fo r de! ive ring these serv ices. While these in stitutions and organizationa l structures may va ry, howeve r, there are bas ic concepts o r "s ignposts" in the ir deve lopme nt th at should be take n into co ns ide rati on . These co n cepts are di scussed in deta il e lsewhere (] ) and a re summari zed be low.
Health for all principles The WHO hea lth fo r a ll strategy fo r Europe (4) provides a cohesive fr a mewo rk for deve loping po li c ies, s trateg ies a nd inte rve nti o ns needed to address iss ues of e nv ironm enta l hea lth The ma in con cepts dea lt with under the hea lth fo r a ll strategy are the fo ll owing.
Equity Environmenta l fac tors present in our soc ieties, such as poor housing a nd ove rcrowdin g, have lo ng bee n recog ni zed as hav in g se ri ous de le te riou s conseque nces for phys ica l hea lth a nd we llbe in g. Th e effects of these factors in relation to mental and social we llbeing are increas ing ly under scrutiny. The economica lly di sadvantaged in our soc ieti es are a ll too ofte n those w ho a lso li ve in the poorest li v ing co ndition s, work in the most haza rdous occupati ons, a nd have lim ited access to proper sa ni ta ti on, c lea n wa te r and a ba lanced, nutri tious di e t.
Environmenta l hea lth services have a rol e in combating these in equities . The widening gaps between the ri ch and poor e lements of soc iety can ofte n be gauged by the c ho ices ava il abl e to peopl e re garding the environmenta l conditi ons in whi ch they li ve. Promoting
INTRODUCTION 9
equity can have a significant effect in empowering individuals and communities to have a say in where and how they live, work and play.
lntersectorality The field of environmental health is one in which all sectors (includ ing agricu lture, forestry, energy, industry, transport and tourism) have a role. Isolated decisions and actions cannot solve environmental health problems. In many cases this approach causes new problems or exacerbates existing ones. While the virtues of intersectorality are espoused by many professionals dealing with environmental health issues, turning this declaration of support into reality involves sharing responsibilities and authority. It requires the pooling of skills and experiences, and in some cases putting aside vested professional interests. The benefits for all concerned - governmenta l authorities, the relevant professionals and the public whom they serve - far out weigh the perceived sectoral risks.
Public participation Fostering public participation in environmental health issues goes far beyond the dissemination of information to the public. Providing relevant and timely information that facilitates informed debate is in itself a worthy goal. However, real communication is a two-way proc ess. The development of mechanisms and forums that empower the public to participate in the making and implementing of decisions is a crucia l chal lenge facing environmental health services in the Eu ropean Region.
Democratic principles The core values of democracy revolve around the concepts of indi vidua l and collective entitlements and responsibilities. These include: the rights of individuals to an environment conducive to the highest attai nable leve l of health and we llbeing; entitlement to information and consultation on the state of the environment; consu ltation on plans, decisions and activities likely to affect both the environment and health; and the right of individuals to be involved in decision making processes. It also includes the responsibilities of individu als, and of all sections of society, in protecting the environment in the interest of human health. Environmental health services share these responsibilities, and also have a vital role in asserting the
10 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
democratic rights of individuals and society to participate in the de cision-making process on relevant issues .
International cooperation Environmental health threats may have little regard for international boundaries, but concerted international cooperation and action have proved very effective in dealing with transboundary environmental health issues. The concept of international cooperation also encom passes the need for solidarity among countries and the prioritization of the needs of the worst affected areas in the Region.
Environmental health promotion This concept is based on three integrated actions - advocacy, edu cation and lobbying. The advocacy role of environmenta l health services implies the defence of sound environmental health princi ples in a proactive manner. Environmental health serv ices also have a major role to play in the area of environmental health education. Target audiences include politicians and policy-makers, profession als in other sectors, the genera l public, and workers within the envi ronmental health services themselves.
It could be argued that environmental health professionals have a duty to make representations to governmental bodies on important issues. This can be achieved through a variety of consultative mecha nisms. It can take place within the services themselves, as well as through consultation between government bodies and professional representative groups and other nongovernmental organizations.
Other relevant concepts In addition, there are certain relevant concepts that have been devel oped through other mechanisms and international initiati ves.
Subsidiarity The principle of subsidiarity involves the delegation of decision making powers to the level at which they will be most effective (I 7) and is seen as a means of ensuring that crucial actions are taken by the most appropriate stakeholders. This requires developing capaci ties at the most appropriate level for identifying priorities and as signing them to environmental health problems. It also requires sup port for developing environmental health institutions and serv ices
INTRODUCTION 11
with the necessary decision-making, problem-solving and commu nication skills. It should be emphasized that the subsidiarity concept cannot be applied uniformly throughout the European Region , given the diversity of existing organizational structures.
Sustainable development Sustainab le development is defined as "Development which meets the needs of the present without compromising the ability of future generations to meet their own needs" (6). Sustainable development is a cornerstone principle for the development of environmental health services. It offers a comprehensive policy framework in which an overview can be made of all aspects of policy-making and imple mentation that have an impact on human health. The value of the concept of sustainable development has been generally recognized . Nevertheless, policies that give effect to the implementation of sustain able deve lopment principles have been slower to develop. Environmen tal health services have a pivotal role taking up this challenge.
The precautionary principle The precautionary principle deals with situations in which science and technology cannot provide a full response to issues, leaving a degree of uncertainty in terms of the effects of certain activities, techno logies and products. The general thrust of this principle might be expressed as "where there are sufficient grounds for believing that an activity or a product is likely to cause threat of serious and irrevers ible damage to health or the environment, measures must be taken to reduce or prevent that activity or product, even if there is no fu lly conclusive evidence of a causal link between that activity o r product and the feared consequences" (/8).
Environmenta l health services have an important role to play as advocates of this principle, as partners in the guardianship of its imp lementation, and as proactive communicators of its implications to policy-makers, the economic sectors and society at large.
PATHWAYS INTO THE FIELD OF ENVIRONMENTAL HEALTH
An explanation of the term "environmental health professional" ts crucia l to any meaningful discussion on appropriate curricula .
12 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
In a survey on this question, the Regional Office drew up a list of no fewer than 31 different categories of professional identified by a sam ple of the Member States themselves as being involved in areas re lated to environmental health. Through further research and consul tations (19), the Regional Office has since deve loped a considerably larger list (Box I). This list provides a valuable insight into "environ menta l health" as a concept, a discipline and a field. Given the evolv ing nature of environmental health, it is perhaps advisab le to con sider the limits of this field in terms of horizons rather than boundaries.
Box 1. Professions involved in environmental health
Academics . lecturers . teachers , teacher trainers
Agriculturists Agronomists Architects Bacteriologists Biochemists Chemical process engineers Civil engineers Climatologists Communications experts Disaster preparedness specialists Ecologists Economists Engineering specialists (with postgraduate qualifications)
Entomologists Environmental biologists Environmental chemists Environmental engineers Environmental health administrators Environmental health educators Environmental health managers Environmental health officers Environmental health planners Environmental health technicians Environmental lawyers Epidemiologists (with medical degree) Epidemiologists (without medical degree)
Ergonomists Fire safety officers Food inspectors Food safety specialists Geneticists Geographers Geologists Health promotion experts Hydrogeologists
Hydrologists Hygienists Information scientists Laboratory assistants/technicians Marine scientists Materials technologists Medical specialists (with postgraduate qualifications in the public health area)
Meteorologists Microbiologists Noise inspectors Nuclear safety managers Nutritionists Occupational health nurses Occupational health physicians Occupational hygienists Physicists Political scientists Pollution inspectors Psychologists Public health nurses Public health physicians Public health veterinarians Public relations experts Risk assessors Rural and urban planners Safety inspectors Sanitary engineers Sanitary officers Social scientists Social workers Soil scientists Statisticians Technical assistants Toxicologists Transport planners/managers Water quality inspectors Zoologists
INTRODUCTION 13
Not all of the professionals mentioned in Box I are to be found in every Member State, nor do all of the professions mentioned have an equa l role in delivering environmental health services. Further more, many professionals listed might not consider themselves to be "environm ental health professionals", nor would they describe the organizations or structures within which they work as "environ mental hea lth services".
What the list does demonstrate is the diversity of stakeholders involved in environmental health. This diversity encompasses not only these professionals but also, by implication , the educational institutions involved in their formative and continuing education, their employers and their professional representative groups.
The li st also illustrates the point that many of the professionals in the field of environmental health may be found in both the private and the pub I ic sectors (I).
Having examined the range of professional disciplines involved in many aspects of environmental health , it becomes clear that de veloping relevant curricula for each individual group would be an extreme ly difficult task, not least because of the varied roles of com parable professionals in Member States. The heterogeneous nature of professions , functions and tasks has been discussed in previous WHO consultations. The results of these discussions indicate that the various professionals enter the field of environmental health by a variety of routes.
First, there are those who have been educated and trained spe cifica lly as environmental health specialists, and operate in the envi ronmental health field in a variety of roles and functions. Second, there are a lso those groups who have been trained a generalists or spec ialists in other disciplines, such as medicine, law or engineer ing, and who subsequently undergo further education or in-service professional development to achieve competence in environmental health issues. Third, there are groups of other professionals who, hav ing ri sen through the hierarchy within their given sectors, be come involved in the managerial and policy development aspects of env ironmenta l health services as part of their broadened scope of responsibility. In the case of the two latter groups, these professionals
14 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
may subseq uently work o n e nvironme nta l hea lth issues e ithe r full or part-tim e.
It is c lear that a ll environmenta l hea lth pro fess iona ls do not enter o r opera te w ithin enviro nme nta l hea lth se rvices a t the sa me leve l. T here a re obvious di ffe re nces, both amo ng and between the va rious profess iona l di sc iplines, in te rm s of the type and leve l of experti se required, as we ll as the leve l in the structure of a na ti o na l environ me nta l hea lth se rv ice a t w hi ch such profess io na ls mi g ht typi ca ll y o pe ra te .
Whil e ove rge nera li za ti o n is in a pp ro pri a te, o n th e bas is of th e consulta ti o ns ca rried out it is reasonable to assume that profess ion a ls working in th e environme nta l hea lth fi e ld can be g rouped into three ca tego ri es:
• env ironme nta l hea lth techni c ians/a ides • ge nera li st/spec ia li st environmenta l hea lth profess io na ls • env iro nme nta l hea lth ma nagers.
The pa th ways fo llowed by th ese g roups a re shown in Fi g. 1, to gether w ith the number o f yea rs typi cal ly spent in educa ti on in or der to reach each leve l. The shaded areas show the range of environ me nta l hea lth pro fess iona ls.
As can be seen from Fig. I , those profess iona ls who operate as e nv ironm e nta l hea lth tec hni c ia ns/a ides e ithe r train spec ifically a s suc h, o r o bta in furthe r co mpete nce throug h additi o nal training o r educati o n. Simil a rl y, the spec ia li st env ironmental hea lth profess ion a ls enter the fi e ld hav ing e ither trained as such or through additi onal tra inin g, educatio n or perhaps research. Those in management pos i ti o ns e ither adva nce to these positio ns as environmental hea lth spe c ia li sts o r become invo lved in e nviro nmenta l hea lth issues as man agers in other di sc ip lines.
DEVELOPING EDUCATIONAL CURRICULA
The ma in a im of thi s book is to provide guidance o n curricula for e nviro nm e nt a l hea lth p ro fess io na ls. Th e d eve lo pm e nt o f s uch
Fig. 1. Career pathways for professionals working in environmental health
------------7
Environmental health
technicians/aides (2-3 years)
Additional competences in environmental health (1 year)
General technicians/ assistants (2 years)
I I I I I I I I
Environmental health service managers
(n years)
Managers of other sectors
(n years)
--,----
Additional 1
competences I I
Environmental health
specialists (4-5 years)
in environmental
health (n years)
Allied generalists/ specialists
(medicine, law, engineering,
etc.) (4-5 years)
Secondary education (n years)
I I I I I I I I I
Other professionals
(n years)
Other managers (n years)
16 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
curricula, however, must occur within the context of the overall up grading of education and training programmes for environmental health professionals.
There is an extensive body of literature on the development of education and training programmes generally, as well as specifi cally for health and environmental health. While it is not intended to review these sources here, it may be useful to introduce some of the terms and concepts that will be used throughout this book , and to explain the approach that has been adopted in developing these guide lines. This approach is based on generally accepted models of educational theory and practice. As a starting point, "curricu lum" is taken to mean "the planned organization of a group of related edu cationa l activ iti es" (20).
As stated above, the development of curricula is just one compo nent of planning and conducting overall educat ional programmes. The development of such a programme might be characterized by four main tasks:
I . deciding on learning objectives (see Chapter I for a fuller dis cu sion) appropriate to national environmental health priori ties and needs ;
2. se lecting learning experiences that will contribute to achiev ing these objectives;
3. organizing these learning experiences to maximize their cu mulative effect; and
4. eva lu ating the effectiveness of the education programme 111
attaining its objectives.
The development of educational programmes is best considered a continuing exercise, whereby the infom1ation and experience gath ered is utilized to evaluate and further refine the programme as needed. This experience is also valuable in the subsequent develop ment of new or related education programmes. The "education spi ral" (Fig. 2) is widely used to illustrate this process (20).
A crucial e lement of a ll environmental health education and traini ng programmes is ensuring their relevance to the needs of the society they serve. The identification of a society's environmenta l
INTRODUCTION
Fig. 2. The education spiral
Carrying out the evaluation
Source: Oshaug et al. (20).
Determining priority problems and
defining professional profiles and educational objectives
Preparing and 1ntroduc1ng an
educational programme
17
health-related needs , the formulation of policies to address those needs, and the mobilization of human and other resources to imple ment those policies is a complex process. Achieving this will re quire the involvement of a wide range of stakeholders; it cannot be done in isolation by an educational institution. The implementation of the tasks identified above for the development of an educational programme must therefore be viewed in terms of the existing envi ronmental health policy framework. The relative position of educa tional institutions in this framework is illustrated in Fig. 3.
METHODOLOGY
The essentia l elements of curriculum development are genera lly taken to include the fo ll owing.
• Each course or programme s hould have stated objectives clearly indicati ng the purpose of the course.
18 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
Fig. 3. Framework for developing environmental health policy
Environmental health framework
Agriculture Environment Sectors Transport
Health Ene,iydustry Others I Education I
Environmental health-related
needs of society
• The bac kg round kn owl edge necessa ry to bene fit from th e course should be stated in li sted prerequis ites. Where exemp tions are a ll owed, the conditi ons fo r these should be cl ear.
Th e app roa ches and me th od o log ies m os t appropri a te to achi ev ing the stated learning obj ecti ve should be explic it.
• The content and timetabling of the curriculum must be devel oped with regard to the teac hing methodo log ies, in order to ensure th e re is suffi c ient time to dea l w ith a ll subj ects ad equ a te ly.
• Eva luation of the course, the educati onal progress of students, and the teaching staff are a ll essentia l elements of curriculum deve lopment.
• Readily ava ilabl e and internati onally authoritative publications should be used .
1
Learning Objectives
DEFINITIONS AND TERMINOLOGY
The purpose of this chapter is to discuss the development of learn ing objectives for educational programmes in environmental health . Oshaug et al. ( 16) discuss these issues in some detai I and their find ings are used extensively throughout this document.
Educational objectives are, in essence, what participants in an educational programme should be able to know, understand and do at the end of a learning period. They are also referred to as " learning objectives" as opposed to " teaching objectives", in order to empha size that they define what the learner, not the teacher, should be able to know, understand and do .
The formulation of learning objectives for educational courses in environmental health must be closely linked to the environ mental health needs of the society, to national and international pol icies on environmental health , and to the specific roles that environmental health professionals perform. The overall empha sis is on ensuring re levance between the objectives set and the needs of society that they address. Learning objectives should set out clearly:
• what the learner should be able to do at the end of the learning period;
19
20 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
• the conditions under which the learner should be able to per form the task; and
• the standard to which the learner should be able to perform.
Learning objectives may be general, intermediate or specific. General learning objectives describe in general terms the competences that learners are expected to have at the end of an edu cational programme in order to perform the specific .fiinctions of their categories of environmental health professional.
Intermediate learning objectives express in less general tem1s the competences that environmental health professionals are expected to possess at a certain stage of the educational process in order to perform certain required activities, or to continue their education and training. The sum of these activities defines the functions re ferred to above.
Specific learning objectives describe the task the learner is ex pected to be able to perform, or the behaviour expected, as a result of a specific unit of teaching and/or learning.
WHY DEVELOP EDUCATIONAL OBJECTIVES?
Educational and training programmes have more of a chance of be ing effective if the overall objectives of that programme are clearly expressed. In the absence of clear objectives, it is not possible accu rately to evaluate the effectiveness of such a programme. Neverthe less , learning objectives not only facilitate the effectiveness but, just as importantly, the relevance of educational programmes. To be rel evant, educational programmes must be selectively shaped in terms of the aims to be achieved rather than being the result of non-selec tive mass of knowledge accumulated over time. Modifications to these aims must accordingly be reflected in modifications to the programme. The setting of learning objectives has specific benefits both to society as a whole and to educational institutions.
Benefits to society • Suitably competent, highly motivated environmental health
professionals can be trained, who can fulfil functions, carry
LEARNING OBJECTIVES 21
out activities and perform tasks relevant to the need s of the soc iety they serve.
• The consumers of the services such professional s provide can be protected, by ensuring that on ly those who have demon strated an acceptable leve l of performance will be e ligible to provide the types of service for which they were trained .
• Human resources for environmental health services can be pro vided more effectively and systematically, especia lly if ser v ice planners are aware in advance of the capacities of gradu ates of different educational programmes. On the other hand, educationa l planners need to be aware of the evolving needs of society, and what the environmenta l health services need to do to address those needs , in order to develop relevant learn ing objectives.
• Ongoing evaluation of national and subnational environmen tal health needs can be carried out.
Benefits to educational institutions There are obvious benefits to all those involved, both within and outs ide educational institutions (managers, teachers , students, pro fessionals , employers, etc.) in terms of se lf-evaluation, evaluation of others and eva luati on of the educational programme.
DEVELOPING LEARNING OBJECTIVES
In developing learni ng objectives, three important cons iderations must be borne in mind :
• se lection of the deci sion-makers who will decide on the learn ing objectives, a process that should include a ll the relevant actors (professionals, academics, teachers , students, etc.) on the basis of their background, professional affiliation, compe tence and involvement;
• the quality of information ava il able on env ironmental health status and needs , financia l support, functioning of
22 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
environmental health se rvices, educational problems, and the characteristics of learners and teachers ; and
• the decision-making process for the management of educa tion and human resources , which calls for attention to the timeframe, the steps to be taken and the results expected.
Annex G provides guidelines for the development and eva lua tion of learning objectives for educational programmes for environ menta l health.
THE MISSION OF ENVIRONMENTAL HEALTH SERVICES
To develop the relevant learning objectives for environmental health professionals, it is necessary to formulate an overview of the current and envisaged objectives, functions, activities and tasks of the vari ous categories of environmental health service. These issues are the subject of the companion vo lume to this book (]) , which also iden tifies the various core areas of environmental health as set out in Health .for all targets (5), the Environmental Health Action Plan for Europe (/4), Concern .for Europe's tomorrow (21) , and e lsewhere.
The Environmental Health Action Plan for Europe prov ides a framework for setting the necessary objectives, and the actions and interventions to be carried out by Member States in a wide range of sectors. These objectives and actions are categorized in accordance with a range of criteria that include the nature and extent of the environmental health hazard, evidence of a worsening trend, the tech nica l feasibility and affordability of solutions, and the likely health benefits to be accrued. A full discuss ion of these objectives is also provided in the companion volume (]).
CORE AREAS OF ENVIRONMENTAL HEALTH
Given the divergence in the current understanding of "environmental health" and "environmental hea lth services", it is important first to iden tify the core areas of concern for an environmenta l health service. These have been described in the companion volume, and are set out in Box 2.
LEARNING OBJECTIVES
Box 2. Core areas of environmental health
Environmental health policy Environmental health management Accident and injury prevention and control
Water quality Air quality Food quality and safety Waste management and soil pollution
Human ecology and settlements
Health of people at work Energy Transport management Land-use planning Agriculture Ionizing and nonionizing radiation Noise control Tourism and recreational activities Vector control
FUNCTIONS OF ENVIRONMENTAL HEALTH SERVICES
23
For the purposes of this book , the functions that an environmental health service might carry out in each of the core areas shown in Box 2 are discussed under the following rubrics:
• risk assessment • risk management • risk communication • intersectoral cooperation and consultation • education and training • research.
Risk assessment The Nationa l Academy of Sciences in the United States (22) has defined risk assessment as "the characterization of the potentia l ad verse effects of human exposures to environmental hazards".
Risk is traditionally viewed as a function of exposure or dose, expressing the probability that an adverse outcome will occur in a person or a group exposed to a particular concentration or dose of a hazardous chemical, biological or physical agent. There is now a growing realization that risk assessment must also take account of socia l and economic issues, and that "risk" may occur as a result of exposure to a wide range of socioeconomic conditions (2).
Risk assessment is used to address the following questions.
24 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
• Is exposure to the agent/factor a potential hazard to human health?
• What relationship exists between exposure to the agent/ factor and risk to health?
• What is the extent of exposure to the agent/factor in the popu lation?
• What is the magnitude of the public health problem?
Risk assessment also includes characterizing the uncertainties in the process of determining risk, and in gaining an understanding of risk as perceived by in exposed individuals or groups.
Risk management Risk management involves integrating the results of risk assessment with engineering data and social, economic and political considera tions, weighing policy alternatives, and selecting an appropriate course of action. This process involves evaluating the various actions directed at reducing the health risk and then selecting, promoting and imple menting the appropriate a lternatives. This selection is the synthesis of the scientific information gathered in the course of risk assessment, coupled with the social, economic and political judgements that influ ence decisions on the control of environmental health hazards (23).
Risk communication Risk assessment and management processes must remain cognizant of the stakeholders who ultimately use environmental health infor mation. These include government and regulatory authorities, in dustry, land owners and occupiers, the general public, professional groups and special interest groups. Risk communication involves developing and promoting dialogue among these stakeholders.
Effective risk communication depends on a three-dimensional ma trix of characteristics describing the magnitude of the risk, the degree of knowledge or uncertainty about the process and magnitude of risk in volved, and the nature of the risk both in its natural context and as perceived by the different parties in the communication process (24).
lntersectoral cooperation and consultation Responsibility for protecting and improving environmental health lies not only with those re ponsible for the environment and health
LEARNING OBJECTIVES 25
sectors, but with society as a whole and particularly with the indus try, energy, transport, agriculture and touri sm sectors. Environmen tal health services have the crucial task of ensuring that a holi stic approach to environment health hazards and risks is maintained. This is an integral part of ri sk management, but in practice, it is often neglected . It is dealt with here separately so that specific is sues involved may be highlighted.
Training and education Training may be described as the acquisition of specific task-orien tated ski ll s and knowledge. In many cases, training has a wide range of potential target audiences, including industry and certain profes siona l and technical occupations. Environmental health services are co ncerned not only with developing the capacit ies of professionals within their own ranks, but also with sharing this knowledge with those in other sectors.
A supp ly of well educated, highly motivated graduates and trained professionals who will be the leaders and service managers of the fu ture is essential to the viability of any profess ion or service . To develop sustai nabl e structures, therefore, environmental health services must be invo lved in the education and training of these professionals.
The needs of those professionals current ly working in environ mental health services must also be addressed, and the services that employ them have particular activities and tasks to perform 111 pro moting continuous profess iona l development.
Research Research has supp lied the knowledge and understanding behind the greatest victories in the fight against disease, disability and death (25). In relation to environmental health, there are research activi ties and tasks to be carried out on a number of fronts. Basic research is needed on health hazards in the environment, their causes and the possible means of their prevention. Increasing emphasis is being placed at present on the interaction of low-dose and long-term ex posures to agents and combined exposure to various risk factors. Researc h is a lso required in a host of other fields , however, includ ing the socioeconomic aspects of environmental health management, environmental health risk communication and equity in health.
26 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
The pooling and exchange of research information is also an increasingly important area of concern, and making this infor mation available and understandable to stakeholders is c lo se ly linked to the risk assessment- management- comm unication con tinuum.
ACTIVITIES OF ENVIRONMENTAL HEALTH SERVICES
The companion volume to this book (]) deals in detail with pos sible activities for environmental health services in all the above mentioned core areas of environmental health. A perusal of these will indicate that there are many areas of common activity across each of the relevant core areas. These common activities are repro duced below.
Common risk assessment activities Environmental health services identify potentially hazardous bio logical, chemical, physical or other factors or agents present in or likely to enter the environment, and assess the potential or actual effect of such factors or agents on human health. They compare observed levels with recognized standards or the best available in formation, and determine the relationship between environmental exposure and effects on health.
The exposure of individuals and populations is assessed in rela tion to recognized standards or the best available information, and the results of sampling and analyses programmes fed into the deci sion-making process. The behavioural and socioeconomic patterns underlying risk of exposure must be studied and high-risk behav iour and practices identified, and the social, econom ic and geographi cal distribution of high-risk groups must be determined. The envi ronmental health impact of new developments on the community is assessed, and the social and economic costs and benefits of policies and practices are determined.
The environmental health services also deal with enquiries and comp laints from the general public, and monitor and control the movement of materials across national and international bounda ries.
LEARNING OBJECTIVES 27
Common risk management activities The risk management activities of environmental health services in clude the development of:
• a policy framework for protecting environmental health in the community;
• integrated approaches with key partners in drawing up na tional development plans ;
• economic instruments for the promotion of sustainable tech- no logies and patterns of behaviour;
• environmental health promotion programmes; • codes of practice and protocols for environmental protection; • monitoring and surveillance systems to ensure compliance with
mandatory standards and codes; • a framework and protocols for appropriate self-monitoring and
control by economic sectors; and • community-based strategies to protect the most vulnerable groups.
The services formulate proposals on standards and codes for ex posure limits to potentially hazardous microorganisms and chemi cal and physical agents, and initiate legal and/or economic sanc tions as appropriate for noncompliance with legal standards. They notify and register occurrences of disease related to environmental conditions , participate in the development of codes of practice and standards for promoting sustainable development , and ensure the provision of appropriate levels of treatment for basic amenities such as drinking-water. They instigate the implementation of remedial strat egies, projects and measures as necessary, collaborate in the accredi tation of environmental health laboratories and services as appropri ate, and participate in the formulation and implementation of con tingency plans. Finally, environmental health services must deal with enquiries and complaints from the general public.
Common risk communication activities In the fie ld of risk communication , environmental health services:
I. provide stakeholders with information on the risks associated with potentially hazardous environmental agents;
2 . develop public awareness and education programmes (see also the section below on education and training);
28
3.
4. 5.
6.
7.
8.
9.
I 0.
I I.
12.
13.
ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
liaise with the mass-media to provide accurate information to the public; provide information to high-risk groups; develop information systems for the sharing of data with stakeholders; identify stakeholders with whom lines of communication must be fostered; promote the economic and social benefits of sustainable development strategies; collaborate in the development of early warning systems of natural and man-made disasters; provide information, guidance and reassurance in the event of an emergency; promote public participation in the development of envi ronmental health policy; promote voluntary compliance with legal standards and norms; promote informed discussion on the consequences of de cisions taken; and develop mechanism and forums for the dissemination of information to the public and for the identification of policy options in collaboration with stakeholders.
Common intersectoral cooperation and consultation activities Environmental health services identify key stakeholders in allied sectors with responsibilities in the environmental health field, col laborate with those sectors in developing appropriate economic and legal instruments and in contingency planning, and develop with them a framework for dealing with issues affecting multiple core areas of environmental health. (exposure to lead contamination be ing a prime example). They develop mechanisms for collaboration with the community and nongovernmental organizations, integrated policy and planning mechanism with allied sectors, and integrated policies for the coordination of resources. They also liaise and ne gotiate with international partners.
Common education and training activities Environmental health services develop specific programmes for train ing trainers in environmental health issues, and collaborate in:
LEARNING OBJECTIVES 29
• the development , design and delivery of environmental health education and training programmes for graduate en vironmental health professionals , together with educational institutions , profe ss ional organizations and other stakeholders;
• the development and implementation of educational pro grammes for continuous training and professional develop ment of current environmental health professionals;
• the development of appropriate educational and training pro grammes on environmental health issues for professionals and workers in allied sectors;
• the development, with other sectors, of educational and pub lic awareness campaigns on environmental health issues (see also the section above on risk communication); and
• the accreditation and eva luation of education and training courses for environmental health professionals .
Common research activities In the research field , the services study the socioeconomic fac tors underlying the status of health and the environment, and in vestigate long-term health affects of environmental agents and the psychosocial factors contributing to environmental health sta tus . They also study new technologies for reducing environmen tal pollution , innovative methods for monitoring pollutants, and the economic effects of policies on the environmental health and allied sectors. They initiate epidemiological studies to determine the relationship between exposure and health risk, and carry out comparat ive studies of high-risk groups within the general popu lation.
ENVIRONMENTAL HEALTH COMPETENCE
As stated above, learning objectives are designed to set out what a student should know, understand and be able to do. In the case of environmental health professionals, these should address the func tions, activities and tasks of environmental health services. The term "competent" can be used to describe a high degree of proficiency in working towards these objectives, and participation in carrying out the various functions, activities and tasks.
30 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
There is frequently confusion over the use of the term "compe tence". Similarly, terms such as "knowledge" and "skills" are often used interchangeably, whereas in fact they have specific meanings in an educational context. Competence involves a three-stranded concept incorporating various aspects of human intellect, namely the relevant attitudes, knowledge and skills.
Professional competence is defined as "the ability to carry out a certain professional function , which is made up of a repertoire of professional practices. Competence requires knowledge , appropri ate attitudes and observable mechanical and/or intellectual skills, which together account for the ability to deliver a specified profes sional service" (26).
Attitudes indicate the behaviour a profes ional hould practise. These attitudes may be defined as "the predisposition to perceive, feel or behave in a particular manner .. . ". Knowledge is the theoreti cal knowledge a professional must acquire, and may defined as "the collection of facts , values , information etc . to which one has acces through study, intuition, or experience". Skills indicate the ability to carry out a specific task and may be defined as the "systematic and coordinated pattern of mental and/or physical activity" (26).
"Competent" may refer to or describe individuals, groups or or ganizations exhibiting or possessing competence. "Competence" may be used, in the generic sense, to refer to areas of knowledge, skills and attitudes.
Fig. 4 shows the relationships between these various domains, and suggests some terms that might be used to describe areas of overlap between the domains.
Environmental health professionals, regardless of the wide range of disciplines from which they are drawn or the variety of tasks they perform, should possess some common areas of competence. The range and depth of competence needed by environmental profes sionals to work at different levels will obviously vary with the na ture of their role, the degree of responsibility involved, and specific organizational functions. While such professionals may work at all levels in the public and private sectors, it is important that there is a
LEARNING OBJECTIVES 31
Fig. 4. Domains of human intellect that contribute to competence
common theme unifying them in dealing with environmental health issues.
The domain of attitudes Attitudes form the basis on which environmental health profession a ls perform their duties. It is this framework of values that provides a strong unifying theme between professionals at a ll level s in the environmental health field.
Personal, social and cultural beliefs will have a major role in the development of profess ional values. The beliefs, values and needs of a society will, in many instances, dictate the manner in which that soc iety addresses those needs . For environmental health profession als, the challenge is to address these issues in a manner that bal ances these social, economic, political and cultural factors.
The attitudinal competence needed has been explored in detail by various groups of environmental health profess ional s. In many cases these have been developed by cadres of profess ionals devel oping codes of conduct necessary for them to carry out their duties, and to serve their communities properly. This has often been prompted by groups of like-minded professionals recogniz ing that there is much
32 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
ment in actively developing their own guidelines on professional conduct rather than having them imposed from outside.
Examination of these codes shows that there are broad common themes in terms of the attitudes identified (2 7- 31 ). Proposed basic areas of attitudinal competence required of environmenta l health professionals are given in Box 3.
Box 3. Basic areas of attitudinal competence
Caring attitude towards people Active concern for public health Personal conviction of the need for a safe and healthy environment Willingness to work with and/or lead others as part of a team Mutual respect for and appreciation of the roles of other disciplines Ability to recognize the point at which a problem requires expertise of other professionals Honesty in situations where answers or solutions are not known Desire to learn independently Commitment to strive for personal development Ability to deal with uncertainty Ability to develop and modify thinking in the light of experience Personal and collective integrity Open-mindedness, objectivity and awareness of one's own prejudices Role model in espousing healthy and environmentally friendly lifestyles Sense of belonging to and pride in one's chosen profession Enthusiasm and diligence in one's chosen career Commitment to democratic principles and human rights Commitment to health for all principles Perseverance and commitment in dealing with issues Willingness to take a principled stand on issues of public concern Willingness to reach an honourable compromise on issues Respect for the need for appropriate levels of confidentiality Willingness to accept responsibility and be accountable for one's actions
The domain of knowledge Knowledge has previously been defined as "the col lection of facts , values, information etc. to which one has access through study, re search, intuition, or experience" (26). For most professionals, their education and training are based on developing theoretical know ledge augmented by training in practical skills. The acquisition of competence in one domain leads to understanding and insight into competence in the other domain. It is evident that there are many simi lar activities and tasks to be performed in each of the core areas of environmental health identified earlier, and that there are also common pools of knowledge necessary to carry these out.
LEARNING OBJECTIVES 33
The Frankfurt (7), Rio (9) and He lsinki (/3) tntttattves funda menta lly changed the understanding of and approaches to environ menta l health. In the light of this new understanding, the re levant discip lines covering the field of environmenta l health have broad ened considerab ly.
As can readily be seen from Box 4, environmental hea lth is a tru ly interdisc iplinary field ; no one indiv idua l, discip line or group of professiona ls could possibly aspire to being expert in a ll of these areas of know ledge. Nevertheless, environmenta l health might also be considered a discipline in its own right, a disc ipline based on the advocacy of a holistic and integrated ph il osophy for addressing the interrelationship between environmenta l issues and the various as pects of human health. This philosophy, based on the princ iples set out in the Introduction , cannot be adequately covered by any of the disciplines given in Box 4.
Box 4. Disciplines covering the field of environmental health
Agriculture Biochemistry Biology Biotechnology Built environment Business management Chemistry Earth and environmental sciences Ecology Economics Education Engineering Epidemiology Evaluation sciences General toxicology Genetics Human resources management Hygiene Immunology
Information and communication sciences Law Linguistics Management sciences Mathematics Meteorology Microbiology Molecular biology Occupational medicine Pathology Physics Physiology Political sciences Psychology Social sciences Statistics Urban planning Veterinary science Zoology
Knowledge required in risk assessment The common poo l of knowledge req uired for effective risk assess ment is shown in Box 5. One of these disciplines deserving particu lar mention is epidemiology. This invo lves the study of the distribu tion and determinants of hea lth-re lated states or events in specified popu lations and the app lication of its fi ndings for the prevention or
34 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
Box 5. Common pool of the knowledge required for effective risk assessment
Applied biology Applied mathematics Applied physics Behavioural Science Biomonitoring Ecology Environmental chemistry and biochemistry
Environmental health economics Environmental health impact assessment
Environmental health law Environmental health policy
Epidemiology Information science Linguistics Medicine Microbiology Organizational and human resource management
Pathology Physiology Risk assessment management Social science Toxicology
contro l of health problems . As such, it is a fundamental component of well developed health programmes and the basic quantitative sci ence of public health research and practice (32).
More specifically, environmental epidemio logy is concerned with the adverse health effects provoked or exacerbated by environmen tal factors. Such factors are inclusive of psychosocial conditions re lating to housing, unemployment, educational leve l, poverty and cultural issues.
The multidisciplinary nature of environmental epidemiology is reflected in the variety of specialized scientific disciplines it incor porates. The areas of knowledge should include:
• biologica l and physica l sciences such as toxico logy, radiation biology, clinical med icine and chemistry;
• engineering sciences such as sanitary engineering, industria l hygiene, hydrology meteorology, ventilat ion engineering and acoustics;
• social sciences such as demography and socio logy • economic sciences; and • mathematics and applied statistics.
Specific applied know ledge necessary 1n environmenta l epide miology includes (33):
LEARNING OBJECTIVES 35
• an understanding of ep idemiolog ica l principles as they apply to the fi eld of environmental hea lth ;
• an understanding of the adve rse hea lth effects of va ri ous chemi ca l, phys ica l and biolog ica l ri sk fac tors;
• an understanding of th e concept of ex pos ure ro utes and is- sues re lated to measuring environmental ex pos ures;
• the ability to des ign and carry out epidemi olog ica l studi es; • the ability to assess, va lidate and analyse data; • an understanding and apprec iati on of how to utilize epidemio
logica l data in deve lop ing prevention and contro l strategies; and • an understanding of ri sk management and communicati on.
In additi on to thi s common poo l of know ledge, there are other specific fi elds of knowledge that have parti cul ar relevance to each of the core areas of environmental hea lth (Table I ).
Knowledge required in risk management The areas of kn owledge required fo r effec ti ve ri sk management are quite broad and include the fo ll owing:
• organi za ti onal manage ment • soc ioeco nomic manage ment • probl em so lving and dec ision-making • informati on manage ment • human reso urce manage ment • legal and leg islative knowledge .
Organizational management The range of competences in orga ni za ti onal manage ment encom passes policy, deve lopment , strateg ic and continge ncy pl anning, applied manage ment sc iences and eva luati on of services.
Problem-solving and decision-making Concern for Europe s tomorrow (2 J} identifi es the deve lopment of competences in thi s area as an abso lute priori ty fo r many Member States in th e Europ ea n Reg ion . Th e deve lopm e nt of such co mpetences pl ays a v ita l rol e in identi fy in g, qu anti fy in g and prioriti z ing issues of conce rn . Equally importantly, competence in thi s area includes planning, implementing and eva luating strateg ies and meas ures to address environmental hea lth issues.
36 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
Table 1. Fields of knowledge relevant to the core areas of environmental health
Core Area
Accidents
Water quality
Air quality
Food quality and safety
Waste management and soil pollution
Human ecology and settlements
Health of people at work
Field of knowledge
Predictive modelling of accident scenarios Contingency and logistical management Accident perception and psychology Accident and risk economics
Water and wastewater chemistry Applied hydrology Hydrogeology Marine sciences Hydromechanics Water-supply and wastewater treatment technologies Agricultural , industrial and energy management
Climatology Industrial and energy management Meteorology Atmospheric chemistry Atmospheric and climatological modelling
Agricultural management economics Veterinary science Soil science Food production technology Hazard analysis systems (hazard analysis critical control points methodologies)
Health promotion skills Biotechnology and genetic modification technology
Solid and liquid waste management Soil science Contaminated land management and rehabilitation Waste avoidance management
Construction management Rural management Architecture Urban planning Building and housing science
Ergonomics Occupational safety Environmental protection Engineering technology Occupational hygiene Biotechnology
LEARNING OBJECTIVES 37
Core Area
Energy
Transport management
Motor engineering
Land-use planning
Agriculture
Ionizing and nonionizing radiation
Noise control
Tourism and recreational activities
Vector control
Table 1. (contd)
Field of knowledge
Energy consumption modelling and prediction Long-distance monitoring and remote sensing techniques Geographical information systems (GIS)
Transport and logistics economics Transport modelling
Transport behavioural studies Road safety stud ies
Town and country planning Open space management Nature conservancy and wildlife protection Contaminated land management Agricultural management Natural resource and energy management
Plant and crop sciences Animal husbandry Veterinary science Chemical and pesticide safety Marine and fishery sciences
Natural background radiation monitoring and protection techniques
Nuclear power plant safety auditing Nuclear waste management Radiation monitoring Predictive modelling techniques Rehabilitation techniques for contaminated sites Applied epidemiological skills for investigating exposure to nonionizing radiation sources
Noise exposure assessment techniques Noise-induced annoyance study skills Community noise assessment
Bathing water monitoring Leisure facility control Applied ecology Littoral and estuarine sciences
Entomology Parasitology Applied zoology Infectious disease control techniques
38 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
Socioeconomic management In Concern .for Europe :S- tomorrow one of the fundamental concerns is "whether the economic environment, production and consumption are able and willing to support sustainable development". This cha llenge will be met in diverse ways by Member States acting both unilaterally and as part of the international community. The Environmental Health Action Plan for Europe (14) gives priority to the development of appropriate economic instruments to address many environmental health and sustainable development issues . In this context, there is a crucial need to develop competence in a wide range of social and economic fields within the environmental health services. There is also a need to establish strong intersectoral links to identify strategic allies who can also participate in contributing essenti a l areas of competence to the policy-making process. The burgeoning of private econom ic sectors is a fact of life in all Member States in the European Region. In addition, the private- public sector relationship, the growing move towards deregulation in some countries , and forward planning of national and international economies are issues of concern for environmental health ser vices.
The relevant fields of knowledge include (though not exc lusively):
• economic evaluation • economic planning and development • environment and health economics • ethics • macroeconomics • marketing • microeconomics • national and international economic policy • organizational management • sociology.
Information management A centra l pillar of modern management systems is the effective management of information. In terms of risk management, this means not simply acting as a passive conduit for the flow of information to and from various sources, but having the capacity to eva luate, as sess and ensure the quality of information. This information must
LEARNING OBJECTIVES 39
then be integrated into the policy- and decision-making process through various information systems and mechanisms .
Human resource management The profound changes in many countries of the European Region , particularly in the last decade have highlighted the necessity for hav ing we ll trained, highly motivated environmental health profession als. The potential benefits of this resource of professional excel lence wi ll not be fully realized, however, unless the skills exist for their organization, delegation, motivation and evaluation . The need to develop competence is therefore a priority for the environmental health services at local, subnational and national levels . The areas of competence associated with this field of management include ele ments of those identified above for economic management, plus:
• employment relations management • labour relations skills • professional representation • labour economics • human resource development and training • human resource research skills • team-building/ leadership skills • communications skills (see also below under Knowledge re
quired in risk communication).
Legal and legislative knowledge Regulatory and legislative measures underpin the policies and ac tivities of environmental health services, and in a wider context all of the economic sectors. The development of competence in this area is a primary concern of environmental health services.
The range of such knowledge is very wide. In addition to scien tific and technical expertise, the development of appropriate policy and legal frameworks must take account of economic, social and political factors, and responsiveness to the needs and expectations of interested parties is also important.
The scope of knowledge required includes the economic, politi ca l and social sciences, international diplomatic and legal matters, and scientific and technical competence.
40 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
Knowledge required in risk communication Environmental health services act as the direct interface between policy makers and those who are subject to that policy. The professionals in such services must routinely explain the degree of knowledge ( or more often the degree of uncertainty) that exists about the processes and magnitude of risk surrounding specific environmenta l health issues.
Experience from large-scale incidents such as that at Chernobyl shows that their psychological effects can be more important than the direct effects of unplanned emissions. Equal ly, failure to com municate the full extent of a pollution episode or other risks can serious ly compromise scientific and political credibility. Conse quently, a basic requirement for all national and subnationa l authori ties is gain the trust of the society they serve, and to ensure credibil ity in their dealings and pronouncements on environmenta l health is sues. The areas of competence required to achieve this are to be found in part in each of the domains of attitudes, knowledge and ski ll s.
The main fields in which knowledge of risk communication needs to be developed include:
• ri sk perception • information management • communication ski ll s • teaching and training.
Risk perception For those involved in risk communication, an understanding of risk perception on the part of exposed populations is vital. Similarly, the abi lity to exp lore, rationalize and understand individual and socia l attitudes to vo luntary and involuntary environmental risks is also important. The pervasive influence of technology on societies, in soc ial and psychosocial terms, and its relevance to environmental health also must be understood. This understanding can contribute significantly to ensuring social pressure and support for policies and laws that may be formulated subsequently.
Information management A fundamental understanding of stat istical techniques, in order to evaluate and communicate scientific knowledge and exposure data,
LEARNING OBJECTIVES 41
is crucial. The ability to facilitate the harmonization of criteria and standards for the collection and transmission of data on environ ment and health is equally important. Building competence in utiliz ing the var ious information media avai lab le must be an absolute priority in environmental health serv ices. The potential of geographi ca l information systems (GIS) as a tool for environmental health services in risk management and in risk communication has yet to be fully explored.
Communication skills Exp laining the rationale behind the prioritization of risks is an im portant element of risk communication. The abi lity to exp lain situa tions to non-experts in scientifica ll y sound, non-technical language requires a hi gh standard of skil ls in communication. An ability to li sten to and assess the concerns of the same people is equally im portant. The development of these skil ls can assist in obtaining the necessary public, political and social support for subsequent inter ve ntions.
A thorough knowledge of mediation and negotiation techniques can be utili zed on a whole range of issues. Environmenta l health professionals have an important role as mediators and faci litators between different and often divergent interests. The competence re quired for this includes an understanding of the needs of the various economi c sectors, the ability to advocate the need to protect and enhance the natural environment and public health, and the media tion sk ill s necessary to find consensus between all the sectors in volved.
Teaching and training All environmenta l health professionals must be able to teach and train, as there are numerous target audiences for appropriate educat ional activities. These include fellow professionals, those in the indu stria l or economic fields, policy-makers and the gen era l public. In too many situations, professionals develop the mis taken belief that the ability to carry out a task is all that is re quired in order to pass on the requisite skills to another indi vidual or group of indi vidua ls. In practice , teaching, the training of trainers and peer training require a high degree of competence (see page 29).
42 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
Risk communication in accident and disaster situations It is not an exaggeration to state that in dealing with accidents and disasters, effective risk communication can save lives. Apart from reducing the risk of fatalities , effective risk communication can have many other benefits, not least the development in all sectors of soci ety of an ethos of safety based on an understanding and apprecia tion of the issues.
In the event or likelihood of accidents or disasters occurring, potentially exposed populations require timely, accurate and unambiguous information . In many instances this information wi ll be disseminated through various types of mass media. The necessity to acquire specific competence for this task shou ld not be under estimated. Effective communication skills that make the best use of the publishing and broadcasting med ia to exp lain scientifica ll y comp lex issues to non-experts are becoming increasingly impor tant to environmental health professionals. Similar ly, being able to explain these issues to policy-makers who may be non-experts is a lso vital. These competences are naturally just as important in dealing with more routine situations, but the sca le of this impor tance is particularly reflected in accident and emergency situa tions .
Given the transboundary nature of the effects of large-scale acci dents and disasters, the ability to communicate information to pro fess ional colleagues, the international community and the media in appropriate languages is also an important cons ideration .
Knowledge required for intersectoral cooperation and consultation The achievement of sustainable development depends on the integration of health, environmenta l, demographic and econom ic deve lopment goals. To achieve this, intersectoral cooperation and consultation are absolutely essential. Environmenta l health services must play a proactive ro le in the promotion and realization of this aim . In practice, this is an integral element of the risk assessment management- communication continuum .
lntersectoral cooperation and consultat ion in each of the core areas involves the environmental health services:
LEARNING OBJECTIVES 43
• identifying appropriate strategic partners in allied sectors; • liaising and consulting on issues of common intere t and con
cern; • developing forums and mechanisms for collaboration with all
interested parties; • collaborating on the development of integrated policies and
plans; • developing the necessary legal and organizational frameworks
to implement integrated policies; • co llaborating and participating in the implementation of inter
ventions and activities; and • co ll aborating in developing and implementing contingency
plans.
The issues that must be regarded as both prerequisite competences in their own right and part of the process of developing intersectoral cooperation include :
• an understanding and appreciation of the activities carried out in other sectors and the role of other allied profe sionals in these sectors;
• an understanding of the significance each of these sectors has, and the contribution each can make, in the drive towards sus tainable development;
• an awareness of the mutual costs and benefits that can ema nate from adopting sustainable development strategies;
• an understanding of the consequence of, and a commitment to, sharing information and resources;
• the ability to work together in a coordinated manner on devel op ing, implementing and evaluating integrated policies and plans; and
• the ab ility to develop a holistic overview of sectoral policies that take cognizance of the wider issues and the greater com mon good.
To ach ieve the level of integration and cooperation necessary, it is cs ential that environmental health professional develop abilities in advocacy. Such skills are necessary in order to communicate these ideas to other professional and policy-makers in allied sectors in terms that are both relevant and meaningful to them.
44 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
Contingency planning for accidents and disasters is one area where there is general support and understanding for the need to develop intersectoral cooperation and consultation. The lessons learned in this sphere over many years should be studied and made relevant to preventive and proactive interventions in environmental health man agement.
Knowledge required in education and training There are numerous target groups for education and training by pro fessionals within the environmental hea lth services. These include fellow profess ional s (including trainee s, students and graduate s), professionals in allied sectors, policy-makers , target occupational groups and the general public . The range of competences, and in particular the applied skill s necessary, will be dictated by the target group involved.
Teachers and trainers must be able to empathize with, communi cate with and stimulate the interest of their audience. It is ironic that many professionals who become involved in education and training are chosen on the basis of their re sea rch or professional abilities rather than their pedagogic abilities (22). While many involved in teaching are outstanding in their professional disciplines , the ability to pass on knowledge and to sustain and reinforce students' motiva tion to learn are not always as well developed.
Specific areas of knowledge include :
• the capacity to stimulate interest but not to impose a view; • the ability to pose questions in a non-directive manner; • the willingness to work as team members in providing a balance
of technical knowledge, practical experience and classical peda gogic skill s that stress the responsibilities of those being taught;
• the ability to identify teaching methods and environments ap propriate to the target audience, the material being taught and the desired outcome;
• the ability to assess and evaluate teaching programmes and their outcomes and to devi se improvements or modifications as required;
• the ability to train other teachers and trainers in appropriate methodologies; and
LEARNING OBJECTIVES 45
• the ability to respond to the needs of specific target groups in terms of developing communication skills appropriate to their situation, examples being linguistic skills for dealing with migrant workers, refugees, etc.
There are many settings in which environmental health profes sionals may become involved in education and training activities. These will frequently be outside the fom1al educational structures or institutions. In fact, many environmental health professionals seek to use their contact with target audiences, in any context, as an open ended educational opportunity. Specialized communication skills are necessary to gain the maximum benefits from this.
The ability to adapt education and training skills to the various communication media available is becoming increasingly important. Developing competence in this area greatly increases the opportu nities available to environmental health professionals to maximize their teaching potential.
Knowledge required in research The importance of research in attaining WHO's European health for all targets can be gauged by the ensuing amount of attention that has been devoted to developing research policies in the European Re gion. T he general competences necessary for research in pursuit of the hea lth for al l targets has been subsequently delineated (34) as:
• know ledge of qualitative and quantitative research methods; • knowledge of research infrastructures at national and interna
tional levels; • the ability to prepare scientifically sound and community-rel
evant research studies; and • information and intellectual property management.
In terms of the competences required to ensure these policies succeed in the field of environmental hea lth, such research must venture into fields that lie outside the traditional domain of health and the related sciences. This includes the biomedical , behavioural and social sciences, as well as engineering, land planning, urban planning, science and technology studies, telematics, communica tion science and others (25).
46 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 4
Priority areas for developing research competence in environmental health Research competence needs to be developed in the continuing im provement of analytical chemistry, specifically with regard to low level, long-term exposure hazards. Improved understanding of the long-term effects of accidents and disasters, in terms of both physi cal and psychological effects, is another area that merits attention.
The availability of advanced predictive modelling techniques, together with recent developments in telernatics, has opened up a new field of research for environmental health workers. The devel opment of competence in this area will become increasingly impor tant. Involvement of expertise from the social and behavioural sci ences is vital in developing research into, and the subsequent pro motion of, community participation in environmental health.
The concept of sustainable development is relatively new to the in ternational community, and research on the relevant strategies and poli cies will be a major focus of attention in the corning years. The competences necessary to develop this research will depend mainly on the ability to integrate information and data from widely diverse sources.
Finally, one vital area of competence previously proposed by WHO on this issue, which perhaps straddles the domains of atti tudes, knowledge and skills, is expressed thus: "Researchers must also have the courage not only to recognize that no further informa tion is needed . . . but to tell policy-makers that the time has come for action" (35).
The domain of skills The skills needed by environmental health professionals cover a very wide range of areas and functions. They can be placed in six catego ries (36).
I. Investigative skills include the ability to:
• design and implement tests, surveys and experiments; • identify the range of information sources available; and • gather information accurately by observation, interview, 111-
spection, survey, examination, assay and research.
LEARNING OBJECTIVES 47
2. Analytical skills include the ability to:
• collate and sort data ; • identify relationships between data sets; • critically exam ine data in terms of their consistency, reli