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Pesticides and National Strategiesfor Health Care Providers:Draft Implementation Plan
Support for this project was made possible through Cooperative Agreement CR 827026-01-0
between the Office of Pesticide Programs of the U.S. Environmental Protection Agency and
The National Environmental Education & Training Foundation.
iii DRAFT
Acknowledgments
The successful development of this Implementation Plan would not have been possible withoutthe efforts of a large number of dedicated people and organizations. The Expert Panel membersgave graciously of their time, experience, and energy in developing the broad national strategies.
The members of the Education, Practice, and Resource Workgroups contributed their time, enthusiasm,and intensive effort during their workshops. Their continued hard work during the review process hasproduced this Plan. The workgroups were also expertly guided by their co-chairs, specifically AndreaLindell and Ameesha Mehta (Education Workgroup), Karen Pane and Bonnie Rogers (Practice WorkGroup), and Mark Robson and Kevin Keaney (Resources Work Group). The Federal Interagency PlanningCommittee has contributed many hours of guidance and oversight to the development of the Plan, andsignificantly helped to organize the Expert Panel and the three workgroups. The Committee also continuesto guide the entire Pesticides and National Strategies for Health Care Providers initiative.
This Plan was drafted collaboratively by Susan West, Ameesha Mehta, Gilah Langner, and Jennifer Bretsch,based on the in-depth work of key stakeholders from across the country. The Plan was developed as partof a larger cooperative agreement for the entire initiative between EPA’s Office of Pesticide Programs andThe National Environmental Education & Training Foundation (NEETF). Susan West, Senior Directorfor Health & Environment Programs at NEETF, has managed this cooperative agreement, including theplanning and facilitation of the Expert Panel and workgroup meetings, the drafting of this Plan, andsetting the overall vision for this initiative in collaboration with Ameesha Mehta at EPA. In addition, ateam of NEETF staff devoted many long hours to this effort, including Jennifer Bretsch, Brynn Ellison,Leda Huta, Mary Magnini (Meetings Management, Inc.) and Mia Dell.
Gilah Langner (Stretton Associates, Inc.) provided extensive writing and editing support during theworkgroup sessions, drafted the original workgroup proceedings, and managed the drafting, editing,and graphic design of this Plan.
EPA staff members in the Certification and Worker Protection Branch, Office of Pesticide Programs,were crucial in ensuring the completion of the Plan. Ameesha Mehta, EPA Project Manager, keptthe Plan’s development on track and moving forward. Kevin Keaney, Chief of the Certification andWorker Protection Branch, gave the Plan priority attention. Delta Valente, EPA Project Manager,provided support to ensure the completion of the Plan.
Finally, this Plan is the result of successful collaborative leadership among EPA, NEETF, the federal agencypartners and the stakeholders. The team of collaborative partners is pleased to share this Plan with you.Questions about the content of the Plan can be directed to [email protected].
Photo credits: Photos on pages 13, 18, and 41: Steven Delaney, EPA.
iv DRAFT
Federal Interagency Planning CommitteeU.S. Environmental Protection AgencyOffice of Pesticide Programs
Kevin Keaney, MA, MS
Ameesha Mehta, MPH
Delta Valente, MPA
Jerome Blondell, MPH, PhD
Ana Maria Osorio, MD, MPH
Frank Davido
Office of Pollution Prevention and Toxics
Diane Sheridan
Office of Children’s Health Protection
Elizabeth Blackburn, RN
Office of Ground Water & Drinking Water
Ron Hoffer, MS
Marjorie C. Jones
Sherri Umansky
U.S. EPA Regional LiaisonsJane Horton — Region 4
Don Baumgartner — Region 5
Amy Mysz — Region 5
Allan Welch — Region 10
U.S. Department ofHealth and Human ServicesHealth Resources & Services Administration
(HRSA) Bureau of Health Professions,
Division of Public Health & Allied Health
Barry Stern, MPH
HRSA Office of Planning, Evaluation & Legislation
Karen Pane, RN, MPSA, CMCN
HRSA Bureau of Health
Professions, Division of Medicine
Barbara Brookmyer, MD, MPH
Ruth Kahn, DNSc
HRSA Bureau of Health
Professions, Division of Nursing
Madeleline Hess, PhD, RN
Joan Weiss, PhD, RN, CRNP
HRSA Bureau of Health Professions, Division of
Interdisciplinary, Community-Based Programs
David D. Hanny, PhD, MPH
HRSA Bureau of Primary Health
Care, Migrant Health Program
Eva Montoya
HRSA Office of Rural Health Policy
Cassandra Lyles
National Institute of Occupational Safety & Health
Geoffrey Calvert, MD, MPH
Rosemary Sokas, MD, MOH
Office of Disease Prevention &
Health Promotion
Dalton Paxman, PhD
Agency for Toxic Substances & Disease Registry
Donna Orti, MS
U.S. Department of AgricultureAgricultural Marketing Service
Peter S. Wood, MS
Cooperative State Research,
Education, and Extension Service
Larry Olsen, PhD
U.S. Department of LaborMike Hancock
Other OrganizationsThe National Environmental
Education & Training Foundation
Susan T. West, MPH
Jennifer Bretsch, MS
American Association of Pesticide Safety Educators,
University of Maryland-College Park
Amy E. Brown, PhD
v DRAFT
Expert Panel and Workgroup MembersSheila Brown Arbury, RN, MPH
Association of Occupational andEnvironmental Clinics
Colin AustinMigrant Clinicians Network, andUniversity of North Carolina-Chapel Hill
Joni Berardino, MS, LSWNational Center for Farmworker Health
Angelina Borbon, RNAlameda County Lead PoisoningPrevention Program
Barry Brennan, PhDAmerican Association of Pesticide SafetyEducators, and Extension PesticideCoordinator, University of Hawaii
Amy Brown, PhDAmerican Association of Pesticide SafetyEducators, and University ofMaryland-College Park
Paul J. Brownson, MDThe Dow Chemical Company
Candace Burns, PhD, ARNPNational Organization of Nurse PractitionerFaculties, and University of South FloridaCollege of Nursing
Joan Spyker Cranmer, PhDUniversity of Arkansas Medical School
Miriam CruzEquity Research
Shelley DavisFarmworker Justice Fund, Inc.
Gerardo de Cosio, MDU.S.-Mexico Border Health Association
Susannah Donahue, MPHChildren’s Environmental Health Network
J. Ward Donovan, Jr., MD, FACEPAmerican College of Emergency Physicians,Pennsylvania University Poison Center, andMilton S. Hershey Medical Center
Gerry Eijkenmans, MD, MPHPan American Health Organization
Joe Fedoruk, MD, DABT, CIHAmerican College of Occupational andEnvironmental Medicine
Kesner Flores, EMTCortina Indian Rancheria, WintumEnvironmental Protection Agency
Scottie Ford, MAWest Virginia Department of Agriculture
Jose GarciaEquity Research
Matthew Garabedian, MPHTexas Department of Health
Jeanne Goshorn, MSNational Library of Medicine
Harold Harlan, PhDNational Pest Control Association
Barbara Hatcher, PhD, MPH, RNAmerican Public Health Association
Rugh Henderson, MD, MPHNorth American Agromedicine Consortium,Pennsylvania Agromedicine Program, andPenn State University College of Medicine
Michael Hodgman, MDNational Rural Health Association,and Bassett Healthcare/NY Center forAgricultural Medicine and Health
Allen James, MBA, CAEElizabeth Lawder, BA (alternate)Responsible Industry for a Sound Environment
Linda Kanzleiter, M.Ps.Sc.Celeste Stalk (alternate)Pennsylvania Area Health Education Center,Milton S. Hershey Medical Center
Matthew Keifer, MD, MPHNIOSH Agricultural Health and SafetyCenters, and University of Washington
Kathy Kirkland, MPHAssociation of Occupational andEnvironmental Clinics
Andrea Lindell, DNSc, RNAmerican Association of Colleges of Nursing,and University of Cincinnati College of Nursing
Ann Linden, CNM, MSN, MPHAmerican College of Nurse Midwives
John McCarthy, PhDAmerican Crop Protection Association
vi DRAFT
Claudia Miller, MDUniversity of Texas Health ScienceCenter–San Antonio
Mark Miller, MDAmerican Academy of Pediatrics
Mary Miller, MN, ARNPAmerican Nurses Association, and WashingtonState Department of Labor and Industries
Terry MillerNational Pesticides TelecommunicationsNetwork, and Oregon State University
Rita MonroyNational Alliance for Hispanic Health(formerly National Coalition of HispanicHealth and Human Services Organizations)
Karen Mountain, MBA, MSN, RNMigrant Clinicians Network
Diane MullAssociation of FarmworkerOpportunity Programs
Madaleine Ochinang, MSFormerly with the Consortium forEnvironmental Education in Medicine
Patrick O’Connor-Marer, PhDAmerican Association of Pesticide SafetyEducators, University of California StatewideIPM Project, and University of CaliforniaAgricultural Health and Safety Center
Marcia Allen Owens, JDMinority Health Professions Foundation
Dennis Penzell, DO, FACPSuncoast Community Health Centers, Inc.
Annette Perez, RNC, MSN, CNM, PhDAmerican College of Nurse Midwives,and University of Texas-El Paso,College of Health Sciences
John Pickle, MSEHWeld County Health Department Greeley, CO
Ana Maria PuenteBureau of Primary Health Care, Border Health,Health Resources and Services Administration
Benjamin Ramirez, MD, MPH, FACOEMDuPont Company
Scott Ratzan, MD, MPAAcademy of Educational Development
Susan Rehm, MBAAmerican Academy of Family Physicians
J. Routt Reigart, MDMedical University of South Carolina,Department of Pediatrics
Mark Robson, MD, MPHEnvironmental and Occupational HealthSciences Institute, and Rutgers University
George C. Rodgers, Jr, MD, PhDAmerican Association of Poison Control Centers,and University of Loiusville School of Medicine
Bonnie Rogers, RN, DrPH, COHN-S, FAANAmerican Association of OccupationalHealth Nurses, and University of NorthCarolina-Chapel Hill School of Public Health
Rachel Rosales, MSHPTexas Department of Health
Elaine R. Rubin, PhDAssociation of Academic Health Centers
Barbara SabolW. K. Kellogg Foundation
Barbara Sattler, RN, DrPHUniversity of Maryland School of Nursing
Jackilen Shannon, PhDCouncil of State and Territorial Epidemiologists,and Texas Department of Health
Cathy Simpson, MDWayne State University School of Medicine
Gina Solomon, MD, MPHNatural Resources Defense Council
Elisabeth Spector, MD, MPHAmerican Academy of Family Physicians
Roger F. Suchyta, MDGraham Newson (alternate)Jennifer Stevens (alternate)American Academy of Pediatrics
Greg P. Thomas, PA-CAmerican Academy of Physician Assistants
Leonel Vela, MDMigrant Health Advisory Council, and TexasTech Health Sciences Center
Sheldon Wagner, MDNational Pesticide Medical MonitoringProgram, and Oregon State University
John Wheat, MD, MPHNorth American Agromedicine Consortium,and University of Alabamaat Birmingham, School of Medicine
ContentsExecutive Summary ................................................................................................................... 1
Vision, Expected Outcomes, and Evaluation ......................................................................... 11
Making the Case ...................................................................................................................... 15
Target Audience ....................................................................................................................... 29
Framework of the Plan: A Three-Pronged Strategy ............................................................... 33
Educational Settings ............................................................................................................... 35
Practice Settings ....................................................................................................................... 61
Resources and Tools ................................................................................................................. 85
Conclusion ............................................................................................................................... 99
References............................................................................................................................... 101
Glossary .................................................................................................................................. 105
Appendix A: Expert Panel Proceedings ............................................................................ 107
Appendix B: Summary Proceedings from Workgroups .................................................. 111
Appendix C: Federal Interagency Planning Committee ................................................. 133
List of Exhibits
Tables
1 Components of the Implementation Plan....................................................................... 6
2 Initiative Work Products ................................................................................................... 8
3 Pesticides Most Often Implicated in Symptomatic Illnesses, 1996 .............................. 20
4 Targets, Populations Served, Practice Settings ............................................................... 29
5 Stages of Change Model ................................................................................................. 30
6 Proposed Competencies for Educational Institutions .................................................. 44
7 Proposed Design of Faculty Champions Project ........................................................... 56
8 Expected Practice Skills — Preliminary Outline ........................................................... 68
Figures
1 Framework of the Implementation Plan ......................................................................... 7
2 Projected Timeline for Accomplishing Implementation Plan ........................................ 9
3 Stages of Change and Implementation Plan Components ........................................... 31
1 DRAFT
Executive Summary
Pesticides are ubiquitous in our society in both agricultural and urban sectors. We usepesticides in our homes, in our workplaces, and in our communities. Due to thewidespread dissemination of pesticides, and the potential for related illness and injury
(especially among farmworkers and pesticide handlers), health care providers should beprepared to recognize, manage and prevent pesticide-related health conditions in their patientsand communities. Communities expect that their primary care providers will be prepared todeal with pesticide-related health conditions, as well as other environmental-related illnesses,but often times they are not.
This report, an Implementation Plan for the national initiative on Pesticides and NationalStrategies for Health Care Providers, sets out a strategic direction for the nation to improve therecognition, management, and prevention of pesticide-related health conditions. It will leadto health improvements in both agricultural and urban sectors. The Plan’s vision is for allprimary care providers on the front lines of our health care system to:
J Possess a basic understanding of the health effects associated with pesticide exposures aswell as broader environmental exposures; and
J Take action to ameliorate such effects through clinical and prevention activities.
The Plan sets forth a three-pronged approach to move toward the vision, and includesboth short and long-term components. The Plan will be used to build national consensuson this issue and to gain funding and resource support to implement and evaluate theentire initiative.
The initiative, Pesticides and National Strategies for Health Care Providers, was created bythe U.S. Environmental Protection Agency (EPA) in collaboration with the U.S. Departmentof Health and Human Services (DHHS), the U.S. Department of Agriculture (USDA), theU.S. Department of Labor (DOL), and The National Environmental Education & TrainingFoundation (NEETF). From the outset, this national interagency initiative has beenconceived of as a long-term effort. Sustained funding will be needed to ensure the successof the Plan, and multi-stakeholder involvement is necessary from federal agencies, academicinstitutions, professional organizations, foundations, farmworker and farm groups, industryand trade associations.
2 DRAFT
This Plan focuses on pesticides as an important model which can easily be expanded toincorporate other toxic agents and other related initiatives in the field of environmental health.To avoid duplication of effort, this Plan will be integrated into the broader context of othernational initiatives in educating health providers about occupational and environmental health,including children’s health protection, drinking water, nursing and environmental health,Healthy People 2010, and NEETF’s Wellness and the Environment Initiative. This Plan reflectsthe landmark reports from the Institute of Medicine, National Academy of Sciences (1988,1995) that set forth broad recommendations on environmental health in medicine and nursing,as well as the extensive efforts that have taken place across the country by key stakeholders toaddress this issue. It is hoped that this Plan will pave the way for the strategic next stepsneeded to move forward a common national vision for environmental health awareness,education and training to health care providers.
This Plan, slated for final publication in Fall 2000, and progress on its implementation will beshowcased at a national forum for health care providers scheduled for 2001 in Washington, DC.
The Initiative’s Driving ForcesThis initiative received its impetus from a number of sources.
The Worker Protection StandardA primary contributor is EPA’s Worker Protection Standard, designed to reduce pesticideexposure to agricultural workers, mitigate exposures that occur, and inform agriculturalemployees of the hazards of pesticides. The regulation, implemented in 1995, mandates thatmillions of farmers, pesticide applicators, and farmworkers be educated for such efforts. Thisin turn was expected to create additional demand for services from health care providers.
After the first year of full implementation of the Worker Protection Standard, EPA heldnine public meetings to evaluate the progress of implementation and hear the experienceof the people most affected by the regulation. One clear message from the public meetingswas the need to improve the recognition, diagnosis, and management of adverse healtheffects from pesticide exposures on the part of all primary care providers of the healthcare community.
Although the primary populations affected by pesticides are the 3 to 4.5 million farmworkersin America and the million or more pesticide applicators, pesticides are widely used in theurban sector. Urban and suburban exposures to pesticides through lawn care products andinsecticides in the home and workplace are affecting the population at large. Health careproviders in urban settings are even less likely to “think pesticides” in taking patient historiesor diagnosing illnesses.
3 DRAFT
Other ForcesIn the field of environmental health, the need for improvements in health care providertraining has been expressed by health professional groups, academic institutions, as well asgovernment and community organizations. In 1994, the American Medical Associationadopted a resolution urging Congress, government agencies, and private organizations tosupport improved strategies for the assessment and prevention of pesticide risks. Thesestrategies included systems for reporting pesticide usage and illness, as well as educationalprograms about pesticide risks and benefits. In addition, two Institute of Medicine (IOM)committees addressed the general issue of environmental health education, focusing onnurses and physicians, respectively. Both committees recommended an integration ofenvironmental health issues throughout the various stages of training and clinical practicefor health care providers.
Definition of Environmental HealthA common definition of environmental health has been adopted for purposes of thisinitiative. Environmental health is defined as: “freedom from illness or injury related toexposure to toxic agents and other environmental conditions encountered in the home,workplace, and community environments that are potentially detrimental to humanhealth” (adapted from the Institute of Medicine’s report, Nursing, Health and theEnvironment (Pope et al, 1995)). Pesticide exposures do occur in workplace settings;therefore, environmental health in the context of this Plan is an overarching categorythat includes occupational health.
Building the Initiative – A Collaborative ApproachTo ensure that collaboration and integration at the federal level could be incorporated at allstages of the initiative, EPA established a Federal Interagency Planning Committee inNovember 1997 whose initial membership included representatives from DHHS, USDA,and DOL, as well as EPA. Beginning in February 1998, through a cooperative agreement,the initiative also involved NEETF as a non-federal collaborative partner. NEETF bringsthe expertise of working with a national coalition of health organizations involved inenvironmental health through its Wellness & The Environment Initiative, and has played amajor role in coordinating the initiative with EPA and the federal partners. Several otherfederal agencies have since joined the initiative and other interested federal partners arewelcome to participate.
Expert Panel and WorkgroupsEPA, the Federal Interagency Planning Committee, and NEETF are committed to involving awider group of key stakeholders through all stages of this initiative, beginning with thedevelopment of this Plan. In April 1998, an Expert Panel was convened to identify strategies
4 DRAFT
for educating health care providers on how to recognize, diagnose, manage, and prevent adversehealth effects from pesticide exposures. This workshop reflected the collaborative nature ofthis initiative and the need to involve a wide group of stakeholders in this issue.
An even wider involvement of key stakeholders took place through three workgroup meetings(Education, Practice, and Resources) held in May and August 1999. (Summaries of the ExpertPanel and workgroup meetings are presented in Appendices A and B, respectively.) Workgroupmembers, as liaisons to their organizations, have brought important perspectives to this effortand have ensured that their organizations are kept abreast of the initiative. These keystakeholders will play a further role in outreach and consensus building within theirorganizations and constituencies to move the overall initiative forward.
Strategic Outreach Meetings to Build ConsensusWith the assistance of stakeholders who participated in the Expert Panel and/or the threeworkgroups, the Federal Interagency Planning Committee will conduct strategic outreachmeetings with key professional organizations and decision-making bodies to secure officialendorsements. Efforts are currently underway to participate at various national conferencesfor the purposes of publicizing the Plan and the upcoming national forum, and to begindeveloping support among stakeholders.
Sustained Funding and SupportTo ensure that sustained funding is available for the implementation and evaluation ofboth short and long-term components of this initiative, funding and resource support mustcome from various sources, including federal agencies, professional health organizations,foundations, academia, industry, trade associations, environmental, farm and farmworkerand community-based organizations. It is this type of resource sharing and collaborationthat will determine the success of this initiative and create a win-win situation of all partiesconcerned.
Summary of the Implementation PlanObjectivesThe main purpose of this Plan is to clearly articulate a plan to improve the recognition,management and prevention of pesticide-related health conditions. This Plan also serves asa model for broader efforts to educate health care providers about the spectrum of healthconditions associated with environmental problems. The four main objectives of the Planare to:
J Make the case and raise awareness for why primary health care providers should beeducated about and trained in ways to address health effects from pesticide exposures.
5 DRAFT
J Identify the target audience for the initiative and explain how strategies are designed toreach segments of the audience at different stages of their “readiness to change.”
J Set forth an agenda to build national consensus on this issue and gain funding and resourcesupport to implement the Plan and evaluate the initiative over a ten-year period fromvarious sources including federal agencies, academia, professional health organizations,foundations, farmworker and farm groups, industry, and trade associations.
J Articulate a three-pronged strategy and a set of required elements for education settings,practice settings, and necessary resources and tools.
Strategic FrameworkGiven that primary care providers are educated and trained in different settings, the Planspecifically sets out a three-pronged strategy for effectively reaching them in these settings(see Table 1). The first prong addresses a provider’s formal education, such as medical schoolor nursing school. The second prong targets the practice setting in which a provider worksand participates in professional development. The final prong articulates the resources andtools that providers need to effectively deal with pesticide-related health conditions in theirpractices and communities. Specifically, the three prongs of the strategy are as follows:
1. Educational Settings: Create significant institutional change in educational settings (e.g.,medical schools, nursing schools, residency and practicum programs) so that students inthe health professions are prepared to recognize, manage, and prevent pesticide-relatedhealth conditions across the United States.
2. Practice Settings: Change the practice of primary care so that pesticide-related healthconditions are recognized, effectively managed and prevented in practice settings (e.g.,community clinics, hospitals, work-place clinics) across the United States.
3. Resources and Tools: Create new resources for educational and practice settings thattake into account existing resources, evaluate their quality and suitability for differentaudiences, and assure their availability through an informational gateway.
For both the educational and practice settings, the Plan recommends a similar set of componentprojects and activities (see Figure 1). These components serve as a framework for the cohesiveimplementation of the three-pronged strategy. This Plan intentionally presents the sameconceptual framework for both settings so as to ensure consistency in approach. However, thePlan distinguishes between the settings because they often involve different decision-makersand approaches. The components for the settings are:
J Make the Case for Change
J Define Guidelines for Educational Competencies or Practice Skills
6
Com
pone
nt A
: Mak
e th
e ca
se fo
r cha
nge
in e
duca
tion
alse
ttin
gs —
Dev
elop
an
eff
ecti
ve c
ase
stat
emen
t to
conv
ince
deci
sion
mak
ers
abou
t th
e n
eed
for
envi
ron
men
tal
hea
lth
and
pest
icid
e ed
uca
tion
in m
edic
al a
nd
nu
rsin
g ed
uca
tion
alin
stit
utio
ns.
*Com
pone
nt B
: De
fine
com
pete
ncie
s an
d in
tegr
atio
nst
rate
gies
for
cur
ricul
a —
Pro
duce
Nat
iona
l Gu
idel
ines
that
reco
mm
end
co
mp
eten
cies
sp
ecif
ic t
o t
he
reco
gnit
ion
,m
anag
emen
t and
pre
vent
ion
of p
estic
ide e
xpos
ures
, for
all
basi
can
d a
dva
nce
d t
rain
ing
in m
edic
ine
and
nu
rsin
g; d
efin
eac
com
pany
ing
cont
ent
area
s; s
ugge
st m
etho
ds o
f in
tegr
atio
nin
to c
urri
cula
; and
pro
vide
acc
ess t
o re
leva
nt re
sour
ce m
ater
ials
.
*Com
pone
nt C
: Ass
ess e
duca
tion
al se
ttin
gs —
Con
duct
an
asse
ssm
ent o
f the
targ
et a
udie
nce
of e
duca
tion
al in
stit
utio
ns
to d
eter
min
e (a
) am
oun
t of
exis
tin
g co
urse
wor
k, (
b) fa
cult
ym
embe
rs’ c
urre
nt k
now
ledg
e an
d co
mfo
rt le
vel w
ith
teac
hing
pest
icid
e-re
late
d to
pics
, an
d (c
) ho
w fa
cult
y an
d ed
ucat
ion
alin
stit
utio
ns
will
bes
t re
spon
d to
edu
cati
onal
pro
gram
s an
din
form
atio
nal
res
ourc
es. T
his
asse
ssm
ent
will
be
com
pris
edof
a li
tera
ture
rev
iew
, sur
veys
, an
d fo
cus
grou
ps.
Com
pone
nt D
: Se
cure
off
icia
l en
dors
emen
ts —
E
nsu
reth
e in
tegr
atio
n o
f th
e co
re c
omp
eten
cies
ou
tlin
ed i
n t
he
Nat
ion
al G
uid
elin
es i
nto
ed
uca
tio
nal
in
stit
uti
on
s b
yse
curi
ng
the
off
icia
l en
do
rsem
ents
of
key
pro
fess
ion
alor
gan
izat
ion
s an
d de
cisi
on m
akin
g bo
dies
.
Com
pone
nt E
: St
reng
then
and
bui
ld f
acul
ty c
ham
pion
s—
Cre
ate
and
supp
ort f
acul
ty c
ham
pion
s wit
hin
med
ical
an
dn
ursi
ng
scho
ols
to te
ach
envi
ron
men
tal h
ealt
h an
d pe
stic
ide
edu
cati
on i
n t
he
curr
icu
lum
, an
d to
bri
ng
abou
t ch
ange
wit
hin
thei
r in
stit
utio
ns.
Com
pone
nt F
: Cr
eate
tea
chin
g in
cent
ives
— I
nfl
uen
ceth
e ap
prop
riat
e bo
ards
, org
aniz
atio
ns,
an
d in
stit
utio
ns
that
crea
te b
oard
exa
ms
to in
clu
de
seve
ral k
ey c
omp
eten
cies
on
pest
icid
es a
nd
envi
ron
men
tal h
ealt
h.
* Pri
orit
y P
roje
ct
Tabl
e 1:
Com
pone
nts
of t
he Im
plem
enta
tion
Pla
n
Educ
atio
nal S
etti
ngs
Prac
tice
Set
ting
sRe
sour
ces
and
Tool
s
Com
pone
nt A
: M
ake
the
case
for
pra
ctit
ione
rs —
Dev
elop
an e
ffec
tive
cas
e st
atem
ent t
o co
nvi
nce
pri
mar
y ca
re p
rovi
ders
abo
ut
the
nee
d t
o i
nco
rpo
rate
en
viro
nm
enta
l h
ealt
h a
nd
pest
icid
e aw
aren
ess
into
th
eir
prac
tice
set
tin
gs.
*Com
pone
nt B
: Def
ine
prac
tice
skill
s and
gui
delin
es —
Pro
duce
Nat
ion
al G
uid
elin
es t
hat
rec
omm
end
pra
ctic
e sk
ills
an
dgu
idel
ines
for
the
reco
gnit
ion
, man
agem
ent,
and
prev
enti
on o
fpe
stic
ide
expo
sure
s for
all
prac
tici
ng h
ealth
car
e pr
ovid
ers;
def
ine
acco
mpa
nyin
g co
nte
nt
rela
ted
to e
xpec
ted
beh
avio
r; s
ugg
est
met
hods
of
inte
grat
ion
into
pra
ctic
e an
d tr
ain
ing
sett
ings
; an
dpr
ovid
e ac
cess
to r
elev
ant r
esou
rce
mat
eria
ls.
*Com
pone
nt C
: Ass
ess k
now
ledg
e an
d sk
ills o
f pra
ctiti
oner
s —C
ondu
ct a
n as
sess
men
t of
the
tar
get
audi
ence
of
prim
ary
care
prov
ider
s to
det
erm
ine:
(a)
pro
vide
rs’ c
urre
nt k
now
ledg
e an
d (b
)ho
w p
rovi
ders
will
bes
t re
spon
d to
edu
cati
onal
pro
gram
s an
din
form
atio
nal
reso
urce
s. T
his
asse
ssm
ent
will
be
com
pris
ed o
f a
liter
atur
e re
view
, sur
veys
, and
focu
s gro
ups.
Com
pone
nt D
: Sec
ure
offi
cial
end
orse
men
ts —
En
sure
th
ein
tegr
atio
n o
f th
e ex
pec
ted
prac
tice
ski
lls in
to p
ract
ice
sett
ings
by
secu
rin
g th
e of
fici
al e
nd
orse
men
ts o
f ke
y p
rofe
ssio
nal
orga
niz
atio
ns
and
deci
sion
mak
ing
bodi
es.
Com
pone
nt E
: D
emon
stra
te m
odel
pro
gram
s —
Mob
ilize
pra
ctic
e se
ttin
gs t
o b
eco
me
po
pu
lati
on
-sp
ecif
ic a
nd
to
inco
rpo
rate
en
viro
nm
enta
l co
nsi
der
atio
ns
(sp
ecif
ical
lype
stic
ides
) in
to p
reve
nti
on, e
duca
tion
, dia
gnos
is, a
nd
trea
tmen
t.A
chie
ve
incr
emen
tal,
si
te-s
pec
ific
im
pro
vem
ents
in
iden
tifi
cati
on, e
arly
inte
rven
tion
, an
d pr
even
tion
, as
wel
l as
inm
easu
res
of p
ract
ice-
spec
ific
hea
lth
ou
tcom
es.
By
2010
, h
alf
of a
ll pr
imar
y h
ealt
h c
are
prac
tice
set
tin
gs in
the
Un
ited
Sta
tes
sho
uld
in
corp
ora
te e
nvi
ron
men
tal
con
sid
erat
ion
s in
prev
enti
on, e
duca
tion
, man
agem
ent,
and
refe
rral
.
Com
pone
nt F
: Cre
ate
ince
ntiv
es f
or c
hang
e —
Ide
nti
fy a
nd
prom
ote
a n
um
ber
of
ince
nti
ves
to i
nco
rpor
ate
appr
opri
ate
prev
enti
on, r
ecog
nit
ion
, an
d m
anag
emen
t of
pes
tici
de-r
elat
edhe
alth
con
diti
ons
into
hea
lth
care
pra
ctic
es.
Com
pone
nt A
: Inv
ento
ry e
xist
ing
reso
urce
s — D
eter
min
ew
hat e
duca
tion
al a
nd
info
rmat
ion
al p
rogr
ams a
nd
mat
eria
lsfo
r h
ealt
h c
are
prov
ider
s cu
rren
tly
exis
t in
edu
cati
on a
nd
prac
tice
set
tin
gs a
nd
wh
at g
aps
shou
ld b
e fi
lled.
*Com
pone
nt B
: Es
tabl
ish
a na
tion
al r
evie
w b
oard
—C
reat
e a
nat
ion
al b
ody
to d
eter
min
e as
sess
men
t cri
teri
a an
dev
alu
ate
exis
tin
g re
sou
rces
, w
ith
th
e go
al o
f id
enti
fyin
g,se
lect
ing,
an
d a
sses
sin
g th
e id
eal
reso
urc
es t
hat
pri
mar
yh
ealt
h c
are
pro
vid
ers
use
in b
oth
ed
uca
tion
al a
nd
pra
ctic
ese
ttin
gs f
or p
reve
nti
on, d
iagn
osis
, tre
atm
ent,
and
ref
erra
lof
pes
tici
de-r
elat
ed h
ealt
h c
ondi
tion
s.
*Com
pone
nt C
: Cr
eate
an
info
rmat
ion
gate
way
—E
stab
lish
a pr
int,
tele
phon
e, a
nd
Web
-bas
ed g
atew
ay th
roug
hw
hich
pri
mar
y he
alth
car
e pr
ovid
ers c
an a
cces
s in
form
atio
nan
d ed
uca
tion
al r
esou
rces
.
Com
pone
nt D
: Dev
elop
tea
chin
g/le
arni
ng re
sour
ces
for
educ
atio
nal s
etti
ngs —
Iden
tify
an
d d
evel
op
new
con
ten
tre
sou
rces
, to
ols
, an
d m
eth
od
s fo
r fa
cult
y in
ed
uca
tio
nal
sett
ings
.
Com
pone
nt E
: D
evel
op n
ew r
esou
rces
for
pra
ctic
ese
ttin
gs —
Id
enti
fy a
nd
dev
elop
new
con
ten
t re
sou
rces
,to
ols
, an
d m
eth
od
s fo
r h
ealt
h c
are
pro
vid
ers
in p
ract
ice
sett
ings
.
7 DRAFT
Figure 1: Framework of the Implementation Plan
J Assess Target Audiences in Each Setting
J Secure Key Endorsements
J Demonstrate Success Through Faculty Champions and Practice Models
J Create Incentives for Change.
The Plan also outlines a process to develop the resources and tools necessary to ensure thesuccess of the entire initiative:
J Inventory Resources
J Establish National Review Board and Conduct Evaluation of Resources
J Create Internet-based Information Gateway
J Create New Resources.
8 DRAFT
Table 2 provides a listing of the anticipated work products to be produced in this initiative. Theprojects and products can only be accomplished through partnerships among federal and stateagencies, professional health organizations, academia, foundations, industry, farm and farmworkergroups, environmental groups and trade associations. EPA and the Federal Interagency PlanningCommittee encourage interested parties to come forward with their ideas for implementation.
Timeline and Priority ProjectsA projected timeline identifying the time frame for implementation of the Plan’s componentsis provided in Figure 2. As the timeline shows, several projects have already been initiated,and four component areas will receive priority attention in 2000. They are:
J National Pesticide Competency Guidelines for Education, and National PesticidePractice Skill Guidelines: These two model documents will recommend competenciesfor students and practice skills for practitioners to achieve, respectively, the recognitionand management of pesticide-related health conditions and exposures. Work on theNational Guidelines was initiated in February 2000.
Table 2: Initiative Work Products
J Case Statement for Educational Settings (p. 38)
J Case Statement for Practice Settings (p. 64)
J National Pesticide Competency Guidelines for Education (p. 41)
J National Pesticide Practice Skill Guidelines (p. 67)
J Report on Knowledge, Attitudes, and Skills of Educators and Practitioners (pp. 49, 71)
J Organizational Position Papers Endorsing The Plan (pp. 52, 74)
J Request for Applications/Proposals to Support Faculty Champions (p. 55)
J Request for Applications/Proposals to Support Practice Models (p. 77)
J Network of Successful Faculty Champions (p. 56)
J Network of Successful Practice Models (p. 77)
J Sample Questions for Educational Examinations (p. 58)
J New Monetary, Legal, Community-Based, and Peer-Professional Incentives (p. 80)
J Inventory of Resources (p. 87)
J National Review Board for Resource Materials (p. 89)
J Recommended List of Resources (p. 89)
J Gateway of Resources (print, telephone, Internet) (p. 91)
J New Resources and Materials (pp. 94, 96)
9
Educ
atio
n:
OM
ake
the
case
for
cha
nge
ined
ucat
iona
l set
ting
s
OD
efin
e co
mpe
tenc
ies
and
inte
grat
ion
stra
tegi
es f
or c
urric
ula*
OAs
sess
edu
cati
onal
set
ting
s
OSe
cure
off
icia
l end
orse
men
ts
OSt
reng
then
and
bui
ld fa
culty
cha
mpi
ons
OCr
eate
tea
chin
g in
cent
ives
Prac
tice
:
OM
ake
the
case
for c
hang
e fo
r pra
ctiti
oner
s
OD
efin
e pr
acti
ce s
kills
and
gui
delin
es*
OAs
sess
kno
wle
dge
and
skill
of
prac
titi
oner
s
OSe
cure
off
icia
l end
orse
men
ts
OD
emon
stra
te m
odel
pro
gram
s
OCr
eate
ince
ntiv
es f
or c
hang
e
Reso
urce
s:
OIn
vent
ory
exis
ting
res
ourc
es
OEs
tabl
ish
nati
onal
rev
iew
boa
rd
OCr
eate
info
rmat
ion
gate
way
OD
evel
op t
each
ing/
lear
ning
res
ourc
esfo
r ed
ucat
iona
l set
ting
s
ODe
velo
p ne
w re
sour
ces f
or p
ract
ice
sett
ings
Conv
ene
Nat
iona
l For
um
Proj
ect
Eval
uati
on
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Figu
re 2
: Pro
ject
ed T
imel
ine
for
Acco
mpl
ishi
ng Im
plem
enta
tion
Pla
n (b
ased
on
fund
ing
avai
labi
lity)
2010
*Init
iate
d Fe
b. 2
000
10 DRAFT
J Audience Assessment of Educational Settings and Primary Care Providers: Theassessment report will document the knowledge, attitudes and skills of health care providerfaculty and practitioners on pesticides and environmental health. Work on the audienceassessments will be initiated in 2000.
J Information Gateway: The Gateway will be a print, telephone, and Web-based resourcethrough which primary care providers can easily access information and educationalresources in one place about pesticides. This effort will get underway in 2000.
J National Review Board: The National Review Board will determine assessment criteriaand evaluate existing resources, with the goal of identifying, selecting, and assessing theideal resources that primary care providers use in both the educational and practice settings.This effort will get underway in 2000.
Request for Participation and Public CommentThis draft plan is a working document and will be widely shared and disseminated amongstakeholders in professional associations, health organizations, educational institutions,government agencies and other groups. The Federal Interagency Planning Committee forthis initiative welcomes the widest possible input. The draft Plan will be available forpublic comment through the Federal Register. Questions about the Plan or initiative can bedirected to NEETF at [email protected]. Once comments have been reviewed andincorporated, the final Plan is slated to be published in Fall 2000.
National Forum 2001The Plan, and progress on implementation of the initiative, will be the subject of a nationalforum for health care providers scheduled for 2001 in Washington, DC. The national forum willbe held over two days with an audience of 150-200 health care providers and stakeholders,including key decision-makers from various agencies and organizations. The forum will launchthis national Implementation Plan, showcasing pesticides as a model for other environmentalhealth issues. Progress on the priority projects initiated this year — the National Guidelines,Audience Assessment, Information Gateway, and National Review Board — will be featured atthe forum, in addition to a broad range of educational models, practice models, and resources.
The forum will provide an opportunity to secure endorsement from key stakeholders; build anetwork of health care providers nationwide; announce an RFP to fund components of theImplementation Plan, and hold training workshops for health care providers. EPA and theFederal Interagency Planning Committee members invite interested organizations andinitiatives to participate in the sponsorship, planning, and organization of the national forum.
11 DRAFT
Vision, ExpectedOutcomes, and Evaluation
Vision
The goal of the Pesticides and National Strategies for Health Care Providers initiative isto improve the recognition, management, and prevention of health effects from pesticidepoisonings and exposures. In addition, all primary health care providers should consider
the impact of pesticide overexposures on human health as they treat patients and prevent disease.All physicians, nurses, and other health care providers are expected to possess a basic knowledgeof health effects related to pesticide exposures and an ability to take action to ameliorate sucheffects through clinical and preventive activities. This will be achieved through training andeducation of health professionals, faculty, and students, and the identification, development,dissemination, and use of appropriate resources and tools, in clinical and public health settings.
The initiative is set in the broader context of environmental health and holds as its preamble thefollowing recommendations, adopted from the Institute of Medicine (Pope and Rall, 1995):
J Environmental health concepts will be reflected in all levels of education of primary careproviders, specifically defined as physicians, nurse practitioners, physician assistants, nurses,nurse midwives, and community health workers in the disciplines of family practice, pediatrics,internal medicine, emergency, obstetrics/gynecology, preventive medicine, and public health.
J Interdisciplinary approaches will be used when educating primary health care providersso as to draw upon the expertise from various environmental health disciplines.
J Environmental health content will be an integral part of lifelong learning and continuingeducation of primary care providers.
J Professional associations, public agencies and private organizations will provide moreresources and educational opportunities to enhance environmental health in primarycare practice.
Expected OutcomesBy 2010, the following expected outcomes of the initiative should have occurred:
1. Professional associations, decision-making bodies, academic institutions, and practicesettings have endorsed the need to address health conditions associated with pesticidepoisonings and overexposures.
12 DRAFT
2. The need for educating health care providers about the health effects of pesticide exposuresis an accepted part of primary health care education and practice.
3. Education and practice settings have integrated an endorsed set of educationalcompetencies and practice skills for primary health care providers on pesticide exposures.
4. Evaluated tools and resources are being used by health care providers to recognize, manage,and prevent health effects from pesticide exposures.
5. A faculty champion on this issue is positioned and funded in over 100 academiceducational institutions, including academic health centers and accompanying nursingschools nationwide.
6. Certification, licensing, and accreditation requirements include attention to therecognition, management, and prevention of health effects related to pesticide poisoningsand exposures.
7. Over 100 pilot primary care practices serve as models for effectively integrating attentionto health effects from pesticides in clinical, educational, and/or preventive ways.
8. Primary care providers are integrating attention to the health effects of pesticides in clinical,educational, and/or preventive ways.
9. An Internet gateway effectively guides health care providers and professional organizationsto informational resources and educational materials on the issue.
10. Incentives in the health care system have increased the attention that primary care providerspay to the recognition, management, and prevention of health effects from pesticidepoisonings and exposures.
11. Resource materials on pesticide poisonings are easily located in the leading sources ofinformation for the health care community (e.g., professional journals, newsletters, centralInternet sites, professional meetings).
Evaluation of Expected OutcomesThis initiative has a long-term perspective and ultimately its success will depend on how wellit leads to changes and improved health care in this country. Evaluating its progress along theway and its long-term success will be important, both for making mid-course corrections asneeded, and for learning from its achievements and failures. An evaluation team will becontracted to design and implement the evaluation. The evaluation will begin early on in theinitiative to ensure that measurement indicators are clearly built into all aspects ofimplementation. The evaluation will be both formative and summative in nature so as totrack both process and outcome measures. The following set of indicators will be used toevaluate the components of the plan.
13 DRAFT
Professional Endorsement
J The major professional associations andorganizations involved with theinitiative’s target audiences endorse and/or adopt a position paper supportingthis Implementation Plan.
J Professional journals increase thenumber of peer-reviewed articles andcommentaries making the case forrecognizing, managing, and preventinghealth effects from pesticide poisoningsand exposures.
Educational Institutions
J Over 40 percent of educationalinstitutions take steps towards integrating pesticide education into their settings (e.g.,adopt components into their curriculum from the National Guidelines, hire a facultychampion, hold Grand Round lectures on the topic, create practice-based internshipsthat address the issue).
J Over 100 educational institutions have a “faculty champion” on faculty who integrates apesticide perspective into the education of health professional students.
J Certification and licensing requirements include a component related to pesticides, oraddress the broader understanding of environmental health so that students are tested onat least a portion of the endorsed competencies.
Practice Settings
J Over half of practice settings have taken steps towards building a “model practice” thataddresses health effects related to pesticides (i.e., patient education, history taking,community outreach, use of tools and resources, access to Internet gateway).
J Model practice settings document improvements based on changes in recognizing,managing, and preventing pesticide exposures. Specific models are tracked in high-impactareas (e.g., migrant farmworker communities, urban settings).
J Re-certification and continuing education requirements include a component related topesticides, or address the broader understanding of environmental health so thatpractitioners are evaluated on at least a portion of endorsed practice skills.
J Incentives are in place in the health care system to reward health care providers whorecognize, manage, and prevent pesticide-related health conditions.
“If you make itrelevant to
teachers, they’llfind a way to teach
their students.”— Marcia Owens, JD
Minority HealthProfessions Foundation
14 DRAFT
Utilization of Tools and Resources
J Tools and resources are being used at an increased rate by health care providers as trackedthrough sales, requests, downloading off the Internet, and distribution at conferences.
J An endorsed list of resources is available to health care providers online and through thekey dissemination mechanisms.
Increased Reporting and Surveillance
J More health care providers are reporting suspected pesticide poisoning and exposures tostate and federal agencies.
J States with existing surveillance systems have improved outreach to health care providersstatewide to report suspected cases.
J More states implement pesticide surveillance systems with effective outreach andinvolvement of health care providers.
Improvements Recognized by Communities/General Public
J Community organizations report improved communication and activities by local healthcare providers and clinics.
15 DRAFT
Making the Case
P esticides are ubiquitous in our society. We use them in our homes, workplaces andcommunities. Due to the widespread dissemination of pesticides, and the potential forrelated illness and injury (especially among farmworkers and pesticide handlers),
primary care providers should be prepared to recognize, manage, and prevent pesticide-relatedhealth conditions with their patients and communities.
When pesticide toxicity is discussed, most people usually think of an acute pesticide poisoningincident in an agricultural setting. However, pesticides are also of concern because of potentialchronic health effects from long-term exposures. In addition, pesticide exposure can occur ina number of settings outside agriculture, including urban environments, homes, and schools.For these reasons, patients and communities often look to their primary care providers asimportant sources of information and guidance on suspected pesticide-related healthconditions. All too often, however, providers are not able to respond effectively.
Primary care providers are on the front lines of health care and therefore can play a key role inidentifying and ameliorating potential pesticide poisonings and exposure. However, moreneeds to be done to ensure that health professionals are prepared for this role and that theyknow where to turn for assistance. This includes ensuring that providers can “problem solve”with patients who think an exposure has occurred, readily diagnose if appropriate, providetimely treatment for pesticide-related illnesses, provide prevention education, and, whereappropriate, consult with local authorities. This Plan offers a way for health care professionalsto be effectively prepared through their education and training, and to maintain this knowledgewhile in practice.
This Plan is based on the premise that addressing pesticide-related health conditions can be apart of routine primary care and does not require extensive expertise on the part of the provider.This initiative recognizes that primary care providers are faced with a number of competingpublic health concerns. The goal of the initiative is to build on existing skills in toxicology,pharmacology, history-taking, and risk communication to provide tools that the busy practitionercan use when the need arises. Primary care providers working with high risk populations mayneed to attain a more detailed knowledge of pesticide-related health conditions.
More research is still needed on the health effects of pesticide exposures. Such research effortsshould involve primary care providers. Research should focus on what conditions primarycare providers see in their practices, specifically with regard to chronic exposures. As this
16 DRAFT
initiative evolves, it is recommended that epidemiologic research be developed using a registryof primary care offices to identify conditions requiring further research and documentation.
Following are a number of reasons, accompanied by supporting data, why pesticide-relatedhealth conditions are relevant to the practice of primary care today:
J Patient and Community Concerns
J Recent Public Pesticide Issues
J Potential for Acute Exposures and Effects
J Potential for Chronic Exposures and Effects
J Clinical Case Examples
J Current Provider Training and Education in Environmental Health
Patient and Community ConcernsPrimary care providers are on the front lines of providing health care. Patients and communitiesoften ask for advice about a suspected pesticide exposure or ask the provider to investigate apotential health condition to see if it might be related to pesticides. Public concern aboutpesticides has been documented and often shows up in the questions asked by patients oftheir personal primary care providers. By helping patients problem solve and evaluate risksfrom pesticides, primary care providers can help patients reduce risk to exposure and preventfuture exposures. In addition, an alert clinician will also be able to identify a potential exposurewhen it occurs.
In some instances, providers serve populations that are more actively engaged with pesticides,such as the farmworker community. There are 3 to 4.5 million farmworkers in this countryand a million or more pesticide applicators who are often at greater risk for pesticide exposurebecause of mixing or applying pesticides or working in fields where pesticides are applied. Aprovider community that is more aware of the specific concerns of this population will bebetter prepared to effectively diagnose and treat health conditions, and prevent exposures.
Many members of the public have expressed concern about the risks of cancer, birth defects,reproductive effects, and other conditions from exposure to pesticides. For example, from alist of 30 potentially hazardous activities, use of pesticides was perceived to rank in the top 10most risky activities, higher in “riskiness” than surgery, electric power, swimming, largeconstruction, x-rays, or bicycles (Slovic et al, 1980). Health care providers have an importantrole in helping their patients evaluate the relative risks from different types of environmentalexposures, including pesticides. Health care providers need to be able to counsel patientsabout realistic risks, and avoid unwarranted trivialization or exaggeration of the risks.
17 DRAFT
In large measure, this initiative is intended to help prepare the primary care provider with theinformation, skills, and resources to begin problem solving with patients. The questions inthe shaded box above are only a sampling of the concerns presented to practitioners everyday.This initiative will help primary care providers carry out their responsibilities to help patientsevaluate the risks and determine whether further steps are required.
Recent Public Pesticide IssuesMisuse of Pesticides – Methyl Parathion — Case Studies of MisdiagnosisUnder the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA), EPA regulates anorganophosphate insecticide called methyl parathion for use on specific crops. In the 1980sand 1990s, methyl parathion was widely used illegally in indoor environments by unlicensedapplicators. One published report describes methyl parathion-related illness among sevensiblings, two of whom had a fatal outcome (CDC, 1984). Approximately two days beforethese children were correctly diagnosed, five of them were seen by their local physician andsent back to their contaminated home with a mistaken diagnosis of viral gastroenteritis. Since1984, at least five different states have reported illegal use of methyl parathion inside homes
Providers are often asked basic questions by their patients. Here is a samplingof pesticide-related questions and concerns that patients bring to their visitswith providers:
(1) I received a report from my water utility that said the water contains 0.5 ppbof dibromochloropropane. What is this chemical, what does it mean for myhealth, and what should I do?
(2) I just read in the newspaper that schools in my state are spraying theirbuildings with toxic pesticides. I’m worried because my child has asthmaand sometimes feels worse at school. Could it be the pesticides?
(3) I have a six-month-old child and the cat has fleas. Is it safe to have theexterminator in to flea-bomb the house? The exterminator says it’s safe ifwe stay out for a few hours and open the windows afterwards.
(4) My husband and I are having trouble conceiving a child. We own a farm andhe sprays pesticides. I want to know if the pesticides may be causing a problem.
(5) I get a headache and have difficulty concentrating at the office. I think itmay be because the janitor sprays pesticides at night.
(6) I am a farmworker and was picking celery in the fields. Today I have a rashon my hands and arms. Is it from the chemicals?FR
EQU
ENTL
Y AS
KED
QU
ESTI
ON
S O
F PR
IMAR
Y CA
RE P
ROVI
DERS
18 DRAFT
and businesses. Some people exposed tomethyl parathion in their homesexperienced mild symptoms oforganophosphate poisoning (e.g., nausea,headache, difficulty breathing, blurredvision) and some of them complained totheir health care professionals. A reportsummarizing the 1995 investigations inOhio (where at least 500 homes weretreated illegally) found that 20% or moreof respondents reported symptomsduring the two weeks following methylparathion application (NCEH, 1996).Unfortunately, corrective action was notenacted until 1994. More than 1,500individuals were relocated from theirhome. The estimated clean-up cost forthese incidents is more than $90 million(Environews, 1997).
Misdiagnosis of organophosphatepoisoning can be a severe problem.
Zweiner and Ginsburg (1988) reviewed a case series of 37 infants and children poisoned byorganophosphates and carbamates. Of 20 cases transferred to Children’s Medical Center inDallas, 16 (80%) had an incorrect transfer diagnosis ranging form encephalopathy and seizuredisorder to pneumonia and pertussis.
Each of these cases of misdiagnosis or delayed diagnosis demonstrates the potential for acuteexposures, public concern, and expenses related to the widespread use (and often misuse) ofpesticides in our country. The primary care provider can play a vital role in helping individualsdeal with these exposures. Furthermore, alert providers aware of potential health conditionsrelated to pesticide exposure can become a key link in limiting the spread of “pesticideepidemics” by identifying sentinel cases and bringing them to the attention of appropriatepublic health officials responsible for pesticide-related illness surveillance.
Control of Exotic Pests – Increase in Potential Pesticide Exposures to the PublicA growing number of exotic and public health pests are besieging the United States. Controlof these pests increases the potential for pesticide exposure to large segments of the public.Aerial application of insecticides over residential neighborhoods involving millions of peoplehas recently been conducted in New Jersey for control of malaria-carrying mosquitoes, inNew York City for control of mosquitoes carrying the West Nile virus, and in several Floridacounties for control of the Mediterranean fruit fly (Medfly). Surveillance conducted during
“Even though I know it is very important to diagnose
and treat this problem, we have to start by preventing
the problem in the very first place. That is when we are
going to start seeing some changes in the long run.”— Gerardo de Cosio, MD
U.S.-Mexico Border Health Association
19 DRAFT
the recent Florida Medfly Eradication Program identified 123 individuals with illnesspotentially related to pesticides used in the program (CDC, 1999b). During pesticide sprayingcampaigns to control exotic pests, health care providers are often called upon to providesound preventive advice, and to recognize and manage any pesticide-associated illnesses.Careful documentation and reporting of suspected cases are needed to protect those whomay be unusually susceptible to low-level exposures.
Potential for Acute Exposures and EffectsHealth care providers may be faced with patients who have experienced acute pesticidepoisonings. A pesticide poisoning is considered acute when the onset of symptoms occurshortly after the time of pesticide exposure. Acute pesticide poisonings can differ in theirdegree of severity.
While providers may not see very many acutely poisoned patients, they should possess a basicunderstanding of signs and symptoms, and an ability to diagnose and refer. Oftentimes it isthe primary care provider who identifies possible sentinel cases that signify the presence ofpreviously unrecognized pesticide hazards in the community. By notifying the properauthorities of real or potential poisonings, health care providers can play a critical role inpesticide-related illness surveillance.
Agricultural ExposuresAgriculture accounts for 76 percent of the conventional pesticides used annually(approximately 944 million pounds, not including disinfectants, wood preservatives, orwater treatment chemicals) (U.S. EPA, 1999). Pesticide handlers and agricultural workersappear to be at greatest risk for acute pesticide poisoning. Based on states with requiredreporting of pesticide-related health concerns, EPA estimates there are approximately 250-500 physician-diagnosed cases occur per 100,000 agricultural workers (including pesticidehandlers) (Blondell, 1997). Migrant and seasonal farmworkers are especially at high risksince they often work and live in poor occupational environments where pesticide exposurescan be significant.
Non-Agricultural ExposuresUrban and suburban uses of pesticides can be as high as in some agricultural areas. A 1990EPA survey estimated that 84% of American households used pesticides, most commonlyinsecticides (Whitmore et al, 1992). Homeowners annually use 5-10 pounds of pesticideper acre on their lawns and gardens, many times the amount applied by farmers to cornand soybean fields (Robinson et al, 1994). They also use pesticides in the form ofdisinfectants, including pine oil cleaners, bathroom cleaning products, and cleaning materialsfor swimming pools. In addition, work-related exposures for structural pest control operatorsand workers in nurseries, greenhouses, and landscaping are also of concern in the non-agricultural sector.
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A substantial number of people in the US are at risk of acute pesticide poisoning from non-agricultural uses. One of the major sources of data on acute pesticide poisoning is the ToxicExposure Surveillance System (TESS) maintained by the American Association of PoisonControl Centers (AAPCC). Data collected from poison control centers found that in 1996,over 40,000 adults were sufficiently exposed to various types of pesticides to warrant a call totheir local poison control center. All 40,000 calls were from individuals who had a concernabout overexposure, not requests for information. It is estimated that as many as 60% ofthese individuals developed symptoms of pesticide poisoning. These figures are thought torepresent less than 30% of the incident cases of acute pesticide-related illness in the U.S.(Litovitz et al, 1997; Chafee-Bahamon et al, 1983; Harchelroad et al, 1990; Veltri et al, 1987).
Pesticide exposures among children also warrant concern. In 1996, poison control centerswere notified about approximately 80,000 children (age 0-19) being exposed to commonhousehold pesticides in the United States. It is estimated that one quarter of those childrendeveloped symptoms of pesticide poisoning. In a study of unintentional exposures to pesticides(excluding disinfectants), EPA found that 78,500 such exposures were reported annually topoison control centers in 1985-92, with 92% of them occurring at residences (AAPCC, 1994).Children ages 5 and younger accounted for 63% of the cases.
The majority of pesticide poisonings (85% of symptomatic cases reported to poison controlcenters) have a minor outcome (often treatable at home), 14% have a moderate outcome(typically requiring treatment in a health care facility) and 1% experience a major or fatal
Table 3: Pesticides Most Often Implicated in Symptomatic Illnesses, 1996
Rank Pesticide or Pesticide Class Child Adults and Total*< 6 years 6-19 yrs.
1 Organophosphates 700 3274 4002
2 Pyrethrins and pyrethroids** 1100 2850 3950
3 Pine oil disinfectants 1336 903 2246
4 Hypochlorite disinfectants 808 1291 2109
5 Insect repellents 1081 997 2086
6 Phenol disinfectants 630 405 1040
7 Carbamate insecticides 202 817 1030
8 Organochlorine insecticides 229 454 685
9 Phenoxy herbicides 63 387 453
10 Anticoagulant rodenticides 176 33 209
All other pesticides 6331 11,417 4614
Total all pesticides/ disinfectants 7279 15,015 22,433
* Total includes a small number of cases with unknown age.** Rough estimate: includes some veterinary products not classified by chemical type.Source: Reigart and Roberts, 1999.
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outcome (Litovitz et al, 1997). In 1992-98, there were an estimated 24,000 emergencydepartment visits annually resulting from pesticide exposure, of which 61% of the casesinvolved children younger than 5 (McCaig, 2000; McCaig and Burt, 1999). These figures arelikely under-estimates and may represent only a fraction of the incident cases of acute pesticide-related illness among children.
Pesticides Most Often Associated with Pesticide-Related Health ConditionsOrganophosphate and pyrethroid insecticides are the categories of pesticides most oftenimplicated in acute pesticide-related illnesses reported to poison control centers. Table 3 on theprevious page ranks the class of pesticides most often linked to symptoms in patients, based ondata from TESS. This table includes only unintentional exposures to single pesticide products.
Potential for Chronic Exposures and EffectsPatients and others in the community may also come to providers with concerns about thechronic health effects of both short and long-term exposure to pesticides. While currentscientific evidence does not offer definitive conclusions about the health effects associatedwith chronic exposures to pesticides, early scientific findings lend support to the hypothesisthat overexposures or significant exposures to some pesticides may be associated with theonset of cancer, neurodevelopmental effects, and reproductive effects. A well-informed healthcare provider who possesses a basic understanding of the latest scientific evidence is betterprepared to talk with and counsel patients who are understandably concerned about pesticideexposures and uncertain about the risk of future adverse health effects.
Risk communication is a critical aspect of the therapeutic encounter, and requires activelistening to identify patients’ concerns and fears. It also requires appropriate risk assessment,including an assessment of the pesticide involved, the actual source and route of exposure,whether absorption occurred (and, if so, how much), and an honest appraisal of the state ofknowledge about long-term outcomes. Clinicians face the daunting challenge of providingappropriate reassurance where needed, while being careful not to dismiss a patient’s concernswithout investigating them. Under certain circumstances, the most effective course of actionmay be to refer the patient to an occupational/environmental specialist, and the list of resourcesfor that referral should be readily available in every clinical practice. On the other hand, theprimary care clinician may wish to provide this information directly, and information sourcesare available to help.
Cancer StudiesWith regard to the relationship between chronic pesticide exposure and cancer, EPA hasreceived and reviewed the required studies for predicting cancer effects for numerous activeingredients. Over 60 of these active ingredients have been classified as probable humancarcinogens by EPA or the International Agency for Research on Cancer (www.epa.gov/pesticides/carlist/table.htm). Although most of these pesticides are no longer on the market
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or have had their uses severely restricted, their potential to cause cancer in persons previouslyexposed is still a concern. A review by the National Cancer Institute (NCI) lists 15 pesticidesfor which there is evidence of cancer in human epidemiologic studies (Zahm et al, 1997). Alarge prospective study of commercial pesticide applicators and their spouses is underway inIowa and North Carolina, funded jointly by the National Cancer Institute and EPA, to try todetermine just which pesticides may pose a risk of cancer in humans (Alavanja et al, 1996).
Non-Hodgkin’s lymphoma has been associated with frequent use of 2,4-D, and is alsoassociated with farming (Hoar et al, 1986; Wigle et al, 1990; Zahm et al, 1990). Concerns havealso been raised about the relationship between organochlorine compounds and breast cancerand endometrial cancer, although studies to date have yielded mixed results (Adami et al,1995; Ahlborg et al, 1995; Davis, 1993; and Eubanks, 1997).
Studies on Central Nervous System EffectsMany insecticides and fumigants are designed specifically to target the nervous system of thepest they are intended to control (referred to as neurotoxins). There is increasing humanevidence in the form of case reports and epidemiologic studies that suggests that humansmay experience chronic neurologic or neurobehavioral effects following high levels of exposureto certain types of pesticides (Keifer and Mahurin, 1997). Several reports have also foundchronic neurological sequelae (reduced neurobehavioral function) after acuteorganophosphate (OP) poisoning (Savage et al, 1988; Rosenstock et al, 1991; Steenland et al,1994; Stephans et al, 1995). EPA has concluded that some subset of OP-poisoned subjectsprobably experience persistent neurobehavioral effects as a result of their exposure. InNovember 1999, the Committee on Toxicity of Chemicals in Food, Consumer Products andthe Environment (1999) of the Department of Health in the United Kingdom concluded:
The balance of evidence supports the view that neuropsychological abnormalities canoccur as a long-term complication of acute OP poisoning, particularly if the poisoningis severe. Such abnormalities have been most evident in neuropsychological tests involvingsustained attention and speeded flexible cognitive processing (“mental agility”).
Studies on Reproductive EffectsMany pesticides have been identified as developmental or reproductive toxicants based on animalstudies. “There is increasing evidence for reproductive effects associated with exposure of malesto occupational agents. Some of the best known examples are reductions in fertility and spermcounts in men who were occupationally exposed to dibromochloropropane” (Sever et al, 1997).Dibromochloropropane (DBCP), a nematocide that was banned by EPA in 1979, producedazo-spermia and oligospermia among exposed workers (Whorton et al, 1979). Sever et al (1997)concluded “there is increasing evidence for reproductive and developmental effects of bothmaternal and paternal pesticide exposures. Areas of particular concern include infertility andtime to pregnancy, spontaneous abortion, neural tube defects, and limb reduction defects.”
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Studies on Other Health Effects/Specific PopulationsHypotheses related to pesticide effects on respiratory, cardiovascular, endocrine, and otherbody systems have also been suggested and are currently being studied. The impact of pesticideson child development is also a growing area of research and investigation.
While studies have indicated associations between pesticide exposures and chronic healtheffects, there still remains insufficient evidence to document a causal relationship betweenfrequently used pesticides and long term health effects, except in a few cases such as arsenic-associated cancer, male infertility due to exposure to dibromochloropropane, and neurologicsequelae following severe poisonings with neurotoxic pesticides. Studies that suggestassociations between pesticide exposures and long-term health effects require support fromstudies with stronger research designs before causal relationships can be accepted. Healthcare providers must be taught how to interpret the current state of knowledge in order toassist patients and others in the community who are concerned about long term health effects.
The concern for potential future adverse effects of non-acutely toxic pesticide exposuresrepresents a special challenge to health care providers. The nature of scientific inquiry yieldsassociations between pesticide exposures and health effects long before causal relationshipscan be reasonably concluded. These associations and the publicity they generate can be enoughto raise concerns among patients and the community. Providers should be sensitive to thelevel of concern and the need to provide reassurance, as well as the possibility that a referral toan occupational and environmental medicine specialist may be indicated.
Evaluation of patient concerns about toxic exposures can be complicated by time constraintsand the need to engage in non-clinical efforts. For example, site visits and industrial hygieneconsultations are expensive and not generally part of a private patient’s insurance coverage.Again, primary care providers need to recognize when these efforts are needed and know howto obtain an appropriate referral.
Clinical Case Examples: The Challenge of Diagnosing Pesticide ExposuresFor many pesticides, the short-term and many of the long-term health effects associated withexposure can easily be mistaken for other agents or health conditions. The ability to recognizea potential pesticide exposure will improve a professional’s ability to make the correct diagnosis.To make a timely and accurate diagnosis, primary care providers need to be familiar with thesettings that predispose patients to pesticide exposure, the symptoms associated with theseexposures, and appropriate diagnostic methods.
Case Study 1 – Chronic Health ConditionsAt the Environmental and Occupational Health Sciences Institute (EOHSI) at the Universityof Medicine and Dentistry of New Jersey, two farmers were referred to the occupationalmedicine clinic for problems associated with the use of pesticides. Initially, the concern was
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the possibility of drug interaction and pesticide use. Both farmers had worked in a large limabean operation, and extensively used organophosphate compounds from early in the seasonuntil the harvest. The initial evaluation, along with an industrial hygenist’s evaluation of thefarm, led the health scientists and physicians to conclude that both men were chronicallyexposed to a series of OP compounds. A careful and rigorous evaluation of all activities led toputting in place the use of personal protective equipment, installation of an on-site showerfor washing, and a laundry for pesticide-contaminated clothing. Over a period of 12 months,considerable improvement was noticed. Both men felt better and no longer reported symptomsof blurred vision, lack of concentration, headaches, etc.
A coordinated effort of the Cooperative Extension faculty, as well as the clinical faculty atEOHSI, led to the diagnosis and a very positive outcome. An earlier evaluation by the localphysician did not connect pesticide exposure to the health problems; in fact, the farmers weretold that there were no real problems and they should just continue what they were doing.The wife of one of the farmers pursued the problem aggressively for four years, first going tothe Extension Service and then to the specialists at the university.
Case Study 2 – Aldicarb ExposureThe following case study, reported in the Morbidity and Mortality Weekly Report (CDC,1999a), describes a foodborne outbreak of aldicarb poisoning that occurred when improperlystored and labeled aldicarb was mistakenly used in food preparation.
On July 19, 1998, 20 employees attended a company lunch prepared from homemade foods.Shortly after eating, several persons developed neurologic and gastrointestinal symptoms.Ten visited a hospital emergency department, and two were hospitalized. On July 20, a hospitalinfection-control nurse reported the incident to the Louisiana Office of Public Health, whichthen investigated the outbreak. The lunch consisted of pork roast, boiled rice, cabbage salad,biscuits, and soft drinks. Only the cabbage salad was associated with illness. Of the 16 personswho ate the cabbage salad, 14 became ill (attack rate: 88%); the four persons who had noteaten the cabbage salad did not develop symptoms.
The employee who prepared the cabbage salad reported mixing precut, prepackaged cabbagein a bowl with vinegar and ground black pepper. The black pepper came from a can labeled“black pepper” that he had found 6 weeks before the lunch in the truck of a deceased relative.This black pepper had not been used by the employee for food preparation before the companylunch. The contents of the black pepper container were tested for organophosphate andcarbamate pesticides. Testing showed the granules in the pepper container as 13.7% aldicarb.A 6-gram portion of cabbage salad contained 272.6 parts per million of aldicarb, a level whichcan produce illness in humans. The deceased owner of the pepper can had been a crawfishfarmer, and it is believed that he used aldicarb on bait to prevent destruction of his crawfishnets, ponds, and levees by wild dogs and raccoons.
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Cholinesterase-inhibiting pesticides (i.e., organic phosphates and carbamates), which arewidely used in agriculture, can cause illness if they contaminate food or drinking water.Aldicarb, a regulated carbamate pesticide, is highly toxic. Health care providers and publichealth officials should keep in mind that food poisoning might result from pesticide or otherchemical contamination as well as from infectious organisms.
Case Study 3 – Organophosphate ExposureA couple in their sixties entered their vacation condominium in Hawaii and were immediatelyaware of a strong odor. Three days later they discovered that the odor emanated from a leakingfive-gallon can of liquid Metasystox-R-2, an organophosphate insecticide which was beingstored in a room adjoining the condominium. The chemical container had leaked and saturatedthe floor boards and the adjoining wall, as well as leaking under the condominium.
The Poison Control Center advised them to see a doctor, which they did, complaining ofcontinuing and increasingly severe headaches, blurred vision, and shortness of breath (i.e.,symptoms compatible with organophosphate intoxication). Pulmonary function tests wereperformed and unexpectedly revealed mild obstructive pulmonary disease with the testimproving following use of a bronchodilator. No other testing was performed. The physiciantreated the couple for a mild reactive airway disease and told them to return for further careonly if symptoms persisted. When they inquired about the need to investigate continuing orresidual effects from exposure to the pesticide, the physician did not know how to answer.
When symptoms persisted, the couple called the National Pesticide TelecommunicationNetwork (NTPN) and were advised to return immediately to the physician and request acholinesterase enzyme assay analysis. The results for the male were minimally above the lowernormal range (i.e., consistent with either an acute or resolving intoxication). NPTN advisedthe couple to vacate the condominium and contact the Hawaii Department of Agriculture,which helped identify a commercial laboratory that confirmed the contamination, andprovided clean up. The couple’s symptoms resolved approximately two weeks later.
Case Study 4 — Arsenic ExposuresA clinician examined a rural family of eight with a number of signs and symptoms. Familymembers had conjunctivitis, bronchitis, pneumonia, sensory hyperthesia of the arms andlegs, muscle cramps, dermatitis over the arms, legs and soles of the feet, nosebleeds, earinfections, blackouts and seizures, gastrointestinal disturbances, and severe alopecia. Symptomsbecame most severe during the winter months and tended to remit in summer (Peters et al,1983). These conditions were initially attributed to stress, poor diet, hypochondria, and evenchild abuse. Only when a toxicologist heard about the case from the news media and performedappropriate laboratory tests on environmental samples was the source of the problemidentified, three years later. The problem was found to be burning arsenic-copper-chromatedtreated wood (outdoor grade plywood) in the family’s wood stove.
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These case studies point to the preventable human suffering and death that can be associatedwith delayed or missed diagnoses of pesticide poisoning. Since the use and presence ofpesticides are so ubiquitous in our society, there is a strong argument for sensitizing all primarycare physicians to develop a high index of suspicion and diagnostic acumen, includingconsultation when needed, to respond promptly to patients whose presentations may representpesticide poisoning. While it is anticipated that providers working with high-risk populations— such as in agricultural areas, emergency departments, and pediatrics — will be most sensitiveto this proposition, these cases show the potential for such severe health consequences that allprimary care providers are advised to be vigilant.
Current Provider Training and Education in Environmental HealthHealth care providers are the primary audience for this Plan because the public looks to themfor guidance on health concerns. While some progress has been made in introducingenvironmental health issues into curricula at medical and nursing schools, most healthproviders still do not have adequate knowledge and tools to address patient and communityconcerns. Key studies by recognized medical institutions and committees convened by federalagencies and national scientific bodies have addressed this concern:
J In 1985, only 50% of medical schools addressed occupational and environmental health intheir curricula, with an average of only four hours being taught over four years. By 1992, 66%percent of medical schools required an average of about six hours of study in occupationaland environmental health over four years (Schenk et al, 1996). (See box on next page).
J In 1988, an Institute of Medicine (IOM) committee on the role of the primary carephysician in occupational and environmental medicine recommended that all primarycare physicians be able to identify possible occupational or environmentally inducedconditions and make appropriate referrals (IOM, 1988).
J In December 1994, the American Medical Association adopted a resolution urgingCongress, government agencies, and private organizations to support improved strategiesfor the assessment and prevention of pesticide risks (AMA, 1994).
J Specific recommendations to change medical/nursing education and practice were madeby two IOM committees on medicine and nursing, in 1994 and 1995, respectively. In1995, the Institute of Medicine produced two landmark reports — Environmental Medicine:Integrating a Missing Element into Medical Education and Nursing, Health and theEnvironment — that called for more effective environmental health education and trainingof medical and nursing professionals.
Health care providers can be extremely effective in addressing pesticide exposures in the livesof their patients and in their communities. However, they do not need to become experts inorder to fill an important and crucial role. Some of the important knowledge and skills thatthey should possess include:
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J Recognizing possible signs and symptoms of pesticide exposure
J Taking a brief and relevant environmental and occupational history
J Diagnosing possible associated health conditions, including those of sensitive populationssuch as children and the elderly
J Calling upon an appropriate specialist or expert to assist them
J Having ready access to a recommended referral list of resources and contacts
J Providing basic preventive guidance for patients
J Recognizing when to report exposure incidents to the proper health authorities
J Possessing a basic awareness of environments in which patients live, work, and play
J Identifying possible sentinel cases
J Participating in surveillance systems.
A 1994 survey of environmental medicine content in U.S. medical schools found that:
J Ninety US medical schools (76%) reported requiring environmental medicinecontent in the curriculum. Only two schools (2%) had a dedicated course.
J Eighty-nine schools (75%) indicated that environmental medicine wastaught as part of a required course. Forty-six schools (39%) offered it as anelective course.
J Fifty schools (42%) reported no instruction in taking an exposure history.
J Among schools with required environmental medicine instruction, theaverage time in the curriculum was seven hours over the four years of medicaleducation. An average of three hours of environmental medicine instructionwas provided in preclinical courses and four hours in clinical courses.
J Eighty-one schools (68%) reported some faculty with environmental andoccupational medicine expertise, most often in departments of internalmedicine (42%), community/preventive medicine or public health (37%),and family medicine (28%).
J Nineteen schools indicated innovative or unusual approaches to teachingenvironmental medicine, including small group case discussions, community-based clerkships, and site visits. These schools reported an average of five facultymembers with occupational/environmental medicine expertise, compared withan average of four faculty members for all other schools.
Note: Of the 126 schools surveyed, 119 (94%) responded.
Source: Schenk et al, 1996.
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This initiative emphasizes the provider’s ability to recognize a potential pesticide exposure, tocommunicate effectively, and to access and work with pesticide/environmental health expertsand resources. In an educational setting, this may mean working with an occupational andenvironmental medicine specialist to design and integrate a pesticides module into a toxicologycourse for medical students. In a practice setting, this may involve incorporating anenvironmental history into primary care practice and referring patients to appropriate expertsin the event of a suspected poisoning. User-friendly teaching materials exist for faculty to use,along with user-friendly guides for faculty and curriculum maps indicating where pesticidetopics could be inserted into the curriculum.
Clearly, the issue of pesticide-related health conditions is one that requires the participationof health care providers. The rationale given in this section serves as the underpinning of thethree-pronged strategy in this Plan.
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Target Audience
Table 4: Targets, Populations Served, Practice Settings
Targets Populations Served Practice Settings
Nurses
Nurse Practitioners
Physicians
Physician Assistants
Nurse midwives
Community health workers
Student training
Emergency medical technicians
susceptible populations(elderly, frail elderly, kids)
urban
non-urban
tribal communities
agricultural
migrant farmworkers
underserved populations(environmental justice)
pesticide handlers
hospitals and emergencydepartments
community clinics
medical centers
independent practices
industry, workplaces
alternative points of care
public health departments
poison control centers
schools
For the purpose of this initiative, the target audience is the primary care provider. Primarycare providers work at the front lines of our health care system and therefore need to beable to identify a possible pesticide exposure. For this reason, it is recommended that
all primary care providers possess basic knowledge and skills related to pesticide exposures. Aprimary care provider, for the purpose of this initiative, is defined as:
a physician, nurse, nurse practitioner, physician assistant, nurse midwife, or communityhealth worker specializing in one of the following areas: family medicine, internal medicine,pediatrics, obstetrics/gynecology, emergency medicine, preventive medicine, or public health.
Specialists in occupational and environmental medicine serve as excellent resources both forpurposes of this initiative and for primary providers. However, because they already have ahigher awareness of pesticide issues, specialists in occupational and environmental medicineare not the primary target of this initiative. They are seen as resource professionals for the primarycare providers, as are another major group of physician specialists, medical toxologists.
Primary care providers work in a variety of settings. Table 4 summarizes the target audience,types of populations served, and the range of practice settings commonly encountered. Inaddition to these primary care providers, the target audience also includes key decision-makingbodies in the health profession. A decision-making body, for purposes of this Plan, refers to any
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organization, institution, or individual leader that is vested with decision-making authority for theeducation and practice of health care in the United States. This includes, but is not limited to,curriculum committees, residency review committees, exam development bodies, accreditinginstitutions, organizations representing academic institutions, faculty, and administrators, andinstitutions governing health care practice and requirements. The engagement of, and endorsementby, such bodies is the only way to ensure success of this Plan and the larger initiative.
Understanding the Target AudienceConsulting the available literature on how health professionals learn is an important first stepin determining the most effective approaches to use. One of the models explored in thedevelopment of this Plan is the Stages of Change model (Prochaska et al, 1995) that looks atbehavior change as a process rather than an event, and describes varying levels of motivation,or readiness to change. Reaching primary care providers who are at different stages of changerequires different types of interventions and resources. The model outlines a continuum ofbehavior change that can be used to help understand where the target audience is on thecontinuum, and to effectively reach the audience (through targeted messages, strategies, andprograms) to ensure behavior change. Table 5 outlines the model.
Table 5: Stages of Change Model
Concept Definition Application
Pre-contemplation Unaware of problem; Increase awareness of need forhas not thought through behavior change, personalize information
and risks and benefits
Contemplation Thinking about change in the Motivate, encourage to makenear future specific plans
Decision/Determination Making a plan to change Assist in developing concreteaction plans, setting gradual goals
Action Implementation of Assist with feedback, problemspecific action plans solving, social support,
reinforcement
Maintenance Continuation of desirable Assist in coping, reminders,actions, or repeating periodic finding alternatives, avoidingrecommended step(s) steps/relapses (as applies)
Source: Prochaska et al, 1995.
Applying the stages of change model to the current initiative, the concepts can be consolidatedinto three categories or stages of change:
J Stage 1: Building awareness and motivation — At this stage, the goal is to increase awarenessand motivation by making an effective case, and increasing the motivation to change.
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Figure 3: Stages of Change and Implementation Plan Components
Make the Case
Create Incentives
Secure Endorsements
New Resources
STAGE 1:Awareness and Motivation-Building
Define Competencies
Models of Change
Faculty Champions
Information Gateway
New Resources
STAGE 2:Knowledge and Skill Building
Faculty Champions
Information Gateway
New Resources
STAGE 3:Maintenance and Champion-Building
J Stage 2: Readiness to make changes — To turn readiness into actual change, the goal atthis stage should be to build on knowledge and skills, for example, by creating new resourcesand disseminating them effectively.
J Stage 3: Maintenance, “champions” — For those who have already made a change, thegoal is to maintain support for the change activity and nurture “champions” who willadvocate for change.
When it comes to understanding and dealing with pesticide-related health conditions, manyprimary care providers may currently fall in the first category (Stage 1), particularly those workingin urban areas. Nevertheless, resources should still be created and made available for all threecategories, allowing primary care providers to “self-select” into whichever category fits their needs.Figure 3 shows how the components of this Implementation Plan cover all three stages of changein the target audience.
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Framework of the Plan:A Three-Pronged Strategy
T his Implementation Plan sets forth a three-pronged strategy to reach the goal ofimproving the recognition, management and prevention of health effects from pesticidepoisoning and exposure.
Given that primary care providers are educated and trained in different settings, the Plan setsout a three-pronged strategy for effectively reaching them. The first prong addresses a provider’s“in-service” or formal education, such as in medical school or nursing school. The secondprong targets the practice setting in which a provider works and participates in professionaldevelopment. The final prong articulates the resources and tools that providers need toeffectively deal with pesticide-related health conditions in their practices and communities.The three prongs of the strategy are:
1. Education Settings: Create significant institutional change in educational settings (e.g.,medical schools, nursing schools, residency, and practicum programs) so that students inthe health professions are prepared to recognize, manage, and prevent pesticide poisoningand exposures across the United States.
2. Practice Settings: Change the practice of primary care so that pesticide-related healthconditions are recognized, effectively managed, and prevented in practice settings (e.g.,community clinics, hospitals, work-place clinics) across the United States.
3. Resources and Tools: Create new resources for educational and practice settings thattake into account existing resources, evaluate their quality and suitability for differentaudiences, and assure their availability through an information gateway.
For each setting, the Plan recommends a set of components. These components serve as aframework for the cohesive implementation of the three-pronged strategy. In some cases, thecomponents for both settings are quite similar; in other cases they are significantly different.This Plan intentionally presents the same set of components for both settings so as to ensureconsistency in approach. However, the Plan distinguishes between the settings because theyoften involve different decision-makers and approaches. The components for each setting are:
J Make the Case for Change
J Define Guidelines for Educational Competencies or Practice Skills
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J Assess Target Audiences in Each Setting
J Secure Key Endorsements
J Demonstrate Success Through Faculty Champions and Practice Models
J Create Incentives for Change.
The Plan also outlines a process to develop the resources and tools necessary to ensure thesuccess of the entire initiative:
J Inventory Resources
J Establish National Review Board and Conduct Evaluation of Resources
J Create Internet-based Information Gateway
J Create New Resources.
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Educational Settings
The first prong of the strategy is directed at the educational setting. Educational settings,for purposes of this initiative, are defined as medical schools, nursing schools, academichealth centers, training programs for all levels of nursing education, and medical
residency programs. While the components target the educational setting, they also involvethe professional associations and decision-making bodies that represent and/or influence theeducational setting. These include, for example, the Association of American Medical Colleges,the American Association of Colleges of Nursing, the Association of Academic Health Centers,and the Accreditation Council for Graduate Medical Education, to name a few. The followingcomponents cut across the continuum of systemic change — from raising awareness andassessment, to development of core competencies, to the support of faculty champions andmodel programs.
Component A: Make the case for change in educational settings — Develop an effectivecase statement to convince decision-makers about the need for environmental health andpesticide education in medical and nursing educational institutions.
Component B: Define competencies and integration strategies for curricula — ProduceNational Guidelines that recommend competencies specific to the recognition, managementand prevention of pesticide exposures, for all basic and advanced training in medicine andnursing; defines accompanying content areas; suggests methods of integration into curricula;and provides access to relevant resource materials.
Component C: Assess educational settings — Conduct an assessment of the target audienceof educational institutions to determine (a) amount of existing coursework, (b) facultymembers’ current knowledge and comfort level with teaching pesticide-related topics, and(c) how faculty and educational institutions will best respond to educational programs andinformational resources. This assessment will be comprised of a literature review, surveys,and focus groups.
Component D: Secure official endorsements — Ensure the integration of the corecompetencies outlined in the National Guidelines into educational institutions by securingthe official endorsements of key professional organizations and decision-making bodies.
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Component E: Strengthen and build faculty champions — Create and support facultychampions within medical and nursing schools to teach environmental health and pesticideeducation in the curriculum, and to bring about change within their institutions.
Component F: Create teaching incentives — Influence the appropriate boards, organizations,and institutions that create board exams to include several key competencies on pesticidesand environmental health.
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EDUCATION COMPONENT A:
Make the Case for Changein Educational Settings
StatementDevelop an effective case statement to convince administrators, faculty, and students aboutthe need for environmental health and pesticide education in medical and nursing education.
Expected Outcomes
J A written case statement that documents the key reasons why faculty members andadministrators of academic institutions should be aware of pesticide-related healthconditions, using persuasive data and documentation of the scientific literature, andstressing the importance of teaching pesticides content in their educational curriculum.
J Endorsement by leading national professional associations, national bodies, deans, andfaculty committees.
Target AudienceAwareness and Motivation: This component is targeted at educational institutions and keystrategic organizations that need to be convinced that the issue of pesticides and the need to educatehealth care providers about this issue are relevant to the educational settings of health care providers.
Proposed ActivitiesActivity #1Research and develop a case statement, solicit peer review, and finalize with the input of keystakeholder groups in the field. The target audiences for the case statement are educationalsettings and the organizations that work with them.
Points to be covered in the case statement:
J Specific importance of environmental health education and the breadth of the problemof pesticide-related health conditions.
J Convincing arguments for why pesticides should be in the curriculum, with cited scientificdata, along with relevance to faculty and students.
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J Compelling arguments to gain the attention of health care students and faculty despite thefact that their time and attention are in high demand elsewhere.
J Emphasis that faculty do not need to become experts, and reassurance that experts existin the field who can work with them on coursework and teaching.
J Emphasis on practical learning for students in settings where pesticide exposures may occur.
J Reassurance that user-friendly teaching materials are available for faculty to use, alongwith user-friendly guides, and curriculum maps indicating where pesticide topics couldbe inserted into the curriculum.
J Recommended amount of time to dedicate to pesticides in the curriculum that isreasonable given the other demands on academic institutions.
Activity #2Promote the case statement through effective dissemination mechanisms to administrators,faculty, and curriculum committees, including print and Internet information sources.
Activity #3Publish journal or newsletter articles on “making the case” for the academic setting inprofessional journals and publications.
Activity #4Hold strategic meetings with bodies that accredit health educational institutions and set curricularrequirements, and with national leaders to seek their endorsement of the case statement. Thisincludes identifying a subset of decision-makers who can be influenced by the case statement.
Stakeholders
J Professional associations
J Key accrediting bodies
J Curriculum committees
J Deans/Department chairs
Evaluation of Outcomes/Indicators of Success
J Complete case statement.
J Published articles in professional journals and newsletters.
J Position papers developed and adopted by professional associations.
39
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BackgroundThis component was crafted based on the recognition that we need to raise awareness aboutwhy educating health care providers about pesticide-related health conditions and exposures isso important. Many key decision-makers may still be unconvinced that this is an issue of concern.Although the supporting documentation is there, there is a need to pull the information togetherin a succinct case statement that clearly shows the relevance of this issue to academic institutions.The document will be used in outreach on the Implementation Plan, and will assist the entirefield in “making the case” for the education of health care providers on this topic. The casestatement will complement a similar statement to be created for practice settings.
40
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EDUCATION COMPONENT B:
Define Competencies andIntegration Strategies for Curricula
StatementProduce National Guidelines that recommend competencies specific to the recognition,management and prevention of pesticide exposures, for all basic and advanced training inmedicine and nursing; define accompanying content areas; suggest methods of integrationinto curricula; and provide access to relevant resource materials.
Expected Outcomes
J National Pesticide Competency Guidelines for Education which recommend competencies,content, insertion points into curricula, and resources. The Guidelines will be completedin mid-2000.
J Endorsement of National Guidelines by leading national professional associations.
Target AudienceReadiness to Change: This component is targeted at administrators and faculty in educationalinstitutions. The guidelines are to assist faculty in integrating the recommended corecompetencies into curricula. This component assumes that administrators and facultymembers have been convinced that this is an important topic for their curricula and that theyare ready to change their curricula.
Proposed ActivitiesActivity #1Define the core competencies for educational institutions to teach about pesticides in basicand advanced curricula (See Table 6).1
The intent of Table 6 is to define competencies that could be integrated into existing curricula.The table will link with a complementary document being created for practice settings.
1 An initial start at defining competencies for the three levels of learning was done by a subgroup of the Education Workgroupin May 1999, and was further elaborated in July 1999 by a small committee. Subcommittee members included Andrea Lindell,Candace Burns, James Roberts, Matthew Kiefer, Annie Perez, Joan Weiss, Cleora Wittl, Ameesha Mehta, and Susan West.
41
Activity #2Produce National Pesticide Competency Guidelinesfor Education to educate students about therecognition and management of pesticide-relatedhealth conditions and exposures. A complementarydocument will focus on the practice settings inwhich primary care providers work.
An accompaniment to the Recognition andManagement of Pesticide Poisonings handbook,the National Guidelines will be designed as a user-friendly guide on how to integrate pesticidescontent into curricula. The Guidelines will bedrafted by a team of experts and will contain thefollowing components:
J Recommended competencies.
J Relevant content for each competency area.
J Suggested points of insertion into curricula (expected to vary between medical and nursingschools as well as for basic or advanced training).
J Suggested resources to teach content specific to each competency in educational settings.
The team will be responsible for meeting the following objectives:
1) Analyze existing content in the basic, advanced, and specialty curricula in both nursingand medical institutions, and identify relevance to pesticide competencies.
2) Identify new content to be added to the curriculum for each competency.
3) Determine windows of opportunity for inserting content into existing curricula (bothfor traditional educational programs and problem-based learning programs), for medicineand nursing. Develop a curriculum map — i.e., an outline of what courses are taughtduring each year — highlighting potential points of insertion for pesticide-related content.
4) Identify and provide a list of resources to teach content specific to each competency thatcan be added to a computerized database of curricular content.
5) Develop recommendations for designing and implementing teaching/learning strategieswith course directors, faculty (including deans), and students.
6) Develop strategies/methods to evaluate student competencies.
7) Participate in coordination of content development and windows of opportunity betweenmedicine and nursing in a timely fashion.
“I see us planting seeds at various levels...”— Matthew Keifer, MD, MPH
University of Washington
42
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DRAFT
8) Coordinate with the team designing the complementary practice document.
The National Guidelines will not contain actual teaching modules or resources, but rather providea listing of relevant resources and how to locate them. The document will be published by EPA;the team of experts will be recognized as the primary authors. A peer review process will be setup for reviewers to comment on and make proposed changes to the National Guidelines.
Activity #3Promote the National Guidelines with key stakeholders. Solicit official endorsements andorganizational support of report, including dissemination to their members.
Stakeholders
J Academic institutions
J National professional associations for academic institutions
J Faculty members who have already developed curricula
Evaluation of Outcomes/Indicators of Success
J National Guidelines completed and peer reviewed by at least 10 key individuals andorganizations.
J Endorsement by key stakeholder organizations.
BackgroundIn defining “competencies” in pesticides and environmental health, several key recommendationshave helped to frame this component.
J Build upon existing documents: The competencies must relate to the Institute of Medicinecompetencies for medical and nursing education, so that no duplication of effort occurs.
J Balance between pesticides and environmental health: One of the most difficultquestions is the relative balance between environmental health topics in general andpesticides in particular. Having the competencies deal specifically with pesticides avoidsany charges of duplication, and might even be seen as a useful model for developing othercompetencies in specific areas.
J Focus on basic and advanced levels: Although Table 6 presents competencies for threelevels of learning (basic, advanced, specialty), the focus of the initiative will be on basicand advanced, which are most relevant for training primary care providers. Other
43
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organizations, including the American College of Occupational and EnvironmentalMedicine, American College of Medical Toxicology, and the American Association ofOccupational Health Nurses, are focusing on specialty training.
J Categorize the competencies: The six categories of competencies shown in Table 6 werederived from a combination of the Institute of Medicine’s medicine and nursingrecommendations. They are meant to apply to medical, nursing, and allied health schoolcurricula. The six categories are:
O Basic Knowledge and Concepts of Pesticides
O Diagnosis/Assessment
O Treatment/Intervention/Referrals/Follow-up
O Risk Communication, Advocacy, and Ethics
O Reporting
O Legislative and Regulatory Knowledge.
44 DRAFT
1.Pr
inci
ples
of E
nvir
onm
enta
l
and
Occ
upat
ion
al H
ealt
h
1a.
Un
der
stan
d
pri
nci
ple
s o
f en
vir
on
men
tal
and
occ
up
atio
nal
hea
lth
1b.
Un
ders
tan
d b
road
spe
ctru
m o
f ch
emic
als
clas
sifi
ed a
s
pes
tici
des
an
d a
reas
of u
se (
shou
ld b
e aw
are
of v
ario
us
typ
es o
f p
esti
cid
es)
1c.
Un
ders
tan
d m
ech
anis
ms
and
path
way
s of
exp
osu
re
1a.
Stre
ngt
hen
ski
lls
from
Bas
ic c
omp
eten
cies
1b.
Un
der
stan
d t
emp
ora
l re
lati
on
ship
bet
wee
n
expo
sure
an
d sy
mpt
oms
(Med
icin
e)
1c.
Und
erst
and
adva
nced
toxi
colo
gy, s
peci
fical
ly re
late
d
to o
rgan
opho
spha
tes,
carb
amat
es, a
nd p
yret
hroi
ds
(mos
t com
mon
ly r
epor
ted
pest
icid
es im
plic
ated
in s
ympt
omat
ic il
lnes
s)
1a.
Ap
ply
val
idat
ed e
pid
emio
logi
c an
d
bios
tatis
tical
pri
ncip
les a
nd te
chni
ques
to
anal
yze
inju
ry/i
llnes
s da
ta i
n d
efin
ed
popu
lati
ons
1b.
Und
erst
and
tem
pora
l rel
atio
nshi
p be
twee
n
expo
sure
and
sym
ptom
s (N
ursi
ng)
1c.
Un
der
stan
d a
nd
ap
ply
ad
van
ced
cou
rses
in to
xico
logy
2.In
div
idu
al
and
P
atie
nt
Kn
owle
dge
and
Skill
s
2a.
Be
awar
e of
the
env
iron
men
t in
whi
ch t
he p
atie
nt
(an
d
fam
ily)
lives
, w
orks
, an
d pl
ays
(un
ders
tan
din
g of
th
e
haza
rds
and
pote
nti
al e
xpos
ures
in d
iffe
ren
t set
tin
gs)
2b.
Iden
tify
ris
k fa
cto
rs f
or
pes
tici
de
exp
osu
re (
e.g.
,
occu
pati
on, l
ocat
ion
of h
ome,
vul
ner
able
pop
ulat
ion
s)
2c.
Rec
ogn
ize
that
oth
er fa
mily
mem
bers
may
be
ill a
s w
ell
(Pos
sibl
y du
e to
exp
osu
re in
th
e h
ome)
2d.
Rec
ogn
ize
soci
o-ec
onom
ic i
mpa
cts
on t
he
pati
ent
of
pes
tici
de-r
elat
ed il
lnes
s
2e.
Un
der
stan
d p
ote
nti
al m
ora
l, e
thic
al a
nd
leg
al
impl
icat
ion
s fo
r pa
tien
ts o
f re
port
ing
and
refe
rral
2a.
Stre
ngth
en s
kills
from
Bas
ic c
ompe
tenc
ies
2b.
Und
erst
and
at a
bas
ic l
evel
the
hea
lth e
ffec
ts o
f
orga
noph
osph
ates
and
car
bam
ates
2c.
Iden
tify
ris
ks t
o p
atie
nts
ser
ved
(i.
e.,
spec
ial
vuln
erab
iliti
es o
f ch
ildre
n, t
he
elde
rly)
2a.
App
ly in
divi
dual
pat
ient
inte
rven
tions
to
pre
ven
t or
mit
igat
e ex
pos
ure
an
d/o
r
resu
ltant
hea
lth e
ffec
ts
Spec
ialt
y: F
ello
ws
and
adva
nced
stud
ents
spe
cial
izin
g in
occu
pati
onal
and
env
ironm
enta
lhe
alth
/med
icin
e/nu
rsin
g
Com
pete
ncy
I:Ba
sic
Know
ledg
e an
dCo
ncep
ts o
f Pe
stic
ides
Basi
c: 4
-yea
r m
edic
al s
choo
l,un
derg
radu
ate
nurs
ing,
und
ergr
adua
teal
lied
heal
th p
rofe
ssio
nal e
duca
tion
Adva
nced
: M
edic
al re
side
nts,
adva
nced
prac
tice
nur
sing
stu
dent
s, ph
ysic
ian
assi
stan
t st
uden
ts, o
ther
adv
ance
d de
gree
prog
ram
s (F
acul
ty in
prim
ary
care
wou
ldne
ed t
o be
at
this
leve
l to
teac
h)
3.P
op
ula
tio
n-B
ased
Hea
lth
Kn
owle
dge
and
Skill
s
3a.
Un
der
stan
d p
op
ula
tio
n-b
ased
hea
lth
, in
clu
din
g
epid
emio
logy
3b.
Rec
ogn
ize
soci
o-e
con
om
ic i
mp
acts
of
pes
tici
de-
rela
ted
illn
ess
3c.
Un
der
stan
d
po
ten
tial
m
ora
l,
eth
ical
an
d
lega
l
impl
icat
ions
for t
he c
omm
unit
y of
repo
rtin
g an
d re
ferr
al
3d.
Poss
ess
a ba
sic
awar
enes
s of
th
e ro
le o
f p
reve
nti
on,
gen
eral
aw
aren
ess
of
ben
efit
s o
f al
tern
ativ
es t
o
conv
enti
onal
pes
t co
ntr
ol
3a.
Stre
ngt
hen
ski
lls fr
om B
asic
com
pete
nci
es
3b.
Dev
elo
p m
ore
in
-dep
th k
no
wle
dge
of
the
envi
ron
men
t in
wh
ich
th
ey a
re l
earn
ing
and
prac
tici
ng
3c.
Dev
elop
spec
ific
un
ders
tan
din
g of
com
mun
itie
s
and
popu
lati
ons
at r
isk
for
pest
icid
e ex
posu
re
3d.
Un
ders
tan
d ad
van
ced
epid
emio
logy
, spe
cifi
cally
rela
ted
to p
esti
cide
-rel
ated
poi
son
ings
3a.
Dev
elo
p,
imp
lem
ent,
eva
luat
e an
d
refi
ne
scre
enin
g pr
ogra
ms
for
grou
ps
to i
den
tify
ris
ks f
or d
isea
se o
r in
jury
and
oppo
rtu
nit
ies t
o pr
omot
e w
elln
ess
3b.
App
ly c
omm
un
ity-
base
d in
terv
enti
ons
to p
reve
nt
or m
itig
ate
expo
sure
an
d/
or r
esu
ltan
t h
ealt
h e
ffec
ts
Tabl
e 6:
Pro
pose
d Co
mpe
tenc
ies
for
Educ
atio
nal I
nsti
tuti
ons
45 DRAFT
4.In
form
atio
n a
nd
Res
ourc
es4a
.Id
enti
fy a
nd a
cces
s in
form
atio
n on
pes
tici
des
4b.
Be
awar
e of
impo
rtan
ce o
f inf
orm
atio
n on
pes
tici
de la
bels
4c.
Be
able
to
lo
cate
res
ou
rces
in
clu
din
g W
eb-b
ased
info
rmat
ion
, p
rin
t m
ater
ials
, M
ater
ial
Safe
ty D
ata
Shee
ts (
MSD
S), a
nd
pois
on c
ontr
ol c
ente
rs
4a.
Stre
ngth
en s
kills
from
Bas
ic c
ompe
tenc
ies
4b.
Dem
on
stra
te
abil
ity
to
loca
te
lead
ing
info
rmat
ion
al r
esou
rces
an
d ex
pert
s fo
r h
ealt
h
care
pro
vid
ers
4a.
Use
ap
pro
pri
ate
wri
tten
an
d
com
pu
teri
zed
dat
abas
es (
e.g.
MSD
S,
Reg
istr
y of
Tox
ic E
ffec
ts o
f C
hem
ical
Sub
stan
ces
[RT
EC
S])
to
id
enti
fy
haz
ard
ou
s in
gred
ien
ts o
f ch
emic
al
agen
ts
Spec
ialt
yCo
mpe
tenc
y II:
Dia
gnos
isan
d As
sess
men
tBa
sic
Adva
nced
His
tory
Tak
ing
Dif
fere
nti
al D
iagn
osis
Dia
gnos
is
1a.
Be
able
to t
ake
envi
ron
men
tal h
isto
ry
1b.
Be
awar
e th
at si
gns a
nd
sym
ptom
s of p
esti
cide
exp
osu
re
may
be
non
-sp
ecif
ic (
ther
e is
not
hin
g pa
thog
nom
onic
abou
t m
ost
pest
icid
e sy
mpt
oms)
1c.
Be
able
to
con
side
r p
esti
cide
s in
dif
fere
nti
al d
iagn
osis
(pes
tici
de
exp
osu
res
may
res
ult
in
hea
lth
eff
ects
com
mon
to s
imila
r di
seas
es)
1c.
Rec
ogn
ize
sign
s an
d
sym
pto
ms
of
pes
tici
de
ove
rexp
osu
re,
wit
h p
rio
rity
giv
en t
o w
idel
y-u
sed
pes
tici
des
wit
h i
den
tifi
able
sym
pto
ms,
su
ch a
s
chol
ines
tera
se-i
nh
ibit
ors
and
pyre
thro
ids
1d.
Perf
orm
a c
ompl
ete
and
focu
sed
phys
ical
exa
min
atio
n
as in
dica
ted
(AC
OE
M)
1a.
Stre
ngt
hen
ski
lls fr
om B
asic
com
pete
nci
es
1b.
Ask
pat
ien
ts 2
-3 s
cree
nin
g qu
esti
ons
(stu
den
ts
nee
d to
kn
ow h
ow t
o ta
ke a
full
envi
ron
men
tal
his
tory
bef
ore
they
are
abl
e to
ask
scr
een
ing
ques
tion
s)
1c.
Iden
tify
sig
ns
and
sym
ptom
s of
ove
rexp
osu
re
to a
wid
er r
ange
of
pest
icid
es
1d.
Be
able
to
diag
nos
e pe
stic
ide-
rela
ted
illn
esse
s
rela
ted
to o
rgan
oph
osph
ates
an
d py
reth
roid
s
1e.
Pro
per
ly u
tiliz
e ch
olin
este
rase
tes
tin
g
1a.
Det
erm
ine
the
nat
ure
an
d e
xten
t of
po
ten
tial
pes
tici
de
po
iso
nin
g o
r
ove
rexp
osu
re c
on
sid
erin
g ro
ute
s o
f
expo
sure
an
d ro
utes
of
abso
rpti
on
1b.
Det
ect,
in so
far a
s pos
sibl
e, p
re-c
linic
al
or c
linic
al e
ffec
ts a
risi
ng
from
che
mic
al
expo
sure
1c.
Be
able
to o
rder
/ in
terp
ret a
ppro
pria
te
diag
nos
tic
test
s
1d.
Eff
ecti
vely
dia
gnos
e p
esti
cide
-rel
ated
illn
esse
s
1e.
Pro
vide
con
sult
atio
n o
n d
iagn
osis
1f.
Iden
tify
at
risk
pop
ula
tion
s, in
clu
din
g
child
ren
1g.
Col
labo
rate
wit
h ot
her d
isci
plin
es su
ch
as i
nd
ust
rial
hyg
ien
e, s
anit
aria
ns,
Coo
pera
tive
Ext
ensi
on
Tabl
e 6
(con
tinu
ed)
46 DRAFT
1.Tr
eatm
ent
1a.
Eff
ecti
vely
tre
at h
ealt
h c
ondi
tion
s re
late
d to
pes
tici
de
expo
sure
s (M
edic
ine)
1a.
Stre
ngt
hen
ski
lls fr
om B
asic
com
pete
nci
es
1b.
Eff
ecti
vely
tre
at h
ealt
h c
ondi
tion
s (N
urs
ing)
1a.
Be
able
to
eff
ecti
vely
tre
at s
pec
ific
pes
tici
de-r
elat
ed h
ealt
h c
ondi
tion
s
2a.
Adv
ise
pati
ents
on
how
to
deco
nta
min
ate
pati
ent
and
envi
ron
men
t fo
llow
ing
expo
sure
2a.
Stre
ngt
hen
ski
lls fr
om B
asic
com
pete
nci
es
2b.
Pro
vid
e sp
ecif
ic
guid
ance
o
n
ho
w
to
dec
on
tam
inat
e p
atie
nt
and
en
viro
nm
ent
follo
win
g ov
erex
posu
re
2a.
Iden
tify
an
d p
resc
rib
e ap
pro
pri
ate
per
son
al p
rote
ctiv
e eq
uip
men
t an
d
engi
nee
rin
g co
ntr
ols
fo
r sp
ecif
ic
pes
tici
des
2b.
Dev
elop
an
d m
anag
e a
com
preh
ensi
ve
occu
pati
onal
hea
lth
pro
gram
3.R
efer
rals
3a.
Ref
er t
o a
pp
rop
riat
e sp
ecia
list
(i.
e. o
ccu
pat
ion
al
med
icin
e/nu
rsin
g, i
ndu
stri
al h
ygen
ist,
envi
ron
men
tal
hea
lth
spe
cial
ist,
Coo
pera
tive
Ext
ensi
on)
(Med
icin
e)
3a.
Stre
ngt
hen
ski
lls fr
om B
asic
com
pete
nci
es
3b.
Mak
e ap
pro
pri
ate
refe
rral
s fo
r m
edic
al
diag
nos
is (
Nu
rsin
g)
3a.
Pro
vid
e co
nsu
ltat
ion
on
tre
atm
ent,
inte
rven
tion
, an
d re
ferr
als
Spec
ialt
y
Com
pete
ncy
III:
Trea
tmen
t/In
terv
enti
on/
Refe
rral
s/Fo
llow
-up
Basi
cAd
vanc
ed
4.Fo
llow
-up
4a.
Arr
ange
ap
prop
riat
e fo
llow
-up
(Med
icin
e)4a
.St
ren
gth
en s
kills
from
Bas
ic c
ompe
ten
cies
4b.
Arr
ange
app
rop
riat
e fo
llow
-up
(Nu
rsin
g)
4a.
Pro
vide
con
sult
atio
n o
n fo
llow
-up
Tabl
e 6
(con
tinu
ed)
2.In
terv
enti
on
47 DRAFT
1.R
isk
Com
mu
nic
atio
n1a
.P
rovi
de g
uid
ance
an
d ed
uca
tion
to p
atie
nts
on
how
to
min
imiz
e ex
posu
res
to p
esti
cide
s, a
nd
abou
t th
e ba
sic
rou
tes
of e
xpos
ure
an
d ab
sorp
tion
1b.
Adv
ise
pati
ents
to r
ead
pes
tici
de la
bel
1c.
Ref
er p
atie
nts
to a
ppr
opri
ate
reso
urc
es
1a.
Stre
ngt
hen
ski
lls fr
om B
asic
com
pete
nci
es
1b.
Com
mu
nic
ate
on i
ssu
es o
f ri
sks
and
pu
blic
hea
lth
pro
tect
ion
to t
he
gen
eral
pu
blic
1c.
Pu
blis
h r
esea
rch
an
d in
terv
enti
on f
indi
ngs
in
the
prof
essi
onal
lite
ratu
re
1a.
Com
mu
nic
ate
wit
h m
edia
, th
e pu
blic
,
and
p
oli
cy
mak
ers
on
is
sues
o
f
scie
nti
fic
un
cert
ain
ty
1b.
Pro
vide
exp
ert
test
imon
y on
beh
alf
of
pati
ents
an
d co
mm
un
itie
s
1c.
Pu
bli
sh r
esea
rch
an
d i
nte
rven
tio
n
fin
din
gs in
th
e p
rofe
ssio
nal
lite
ratu
re
2.A
dvoc
acy
2a.
Adv
ocat
e on
beh
alf
of p
atie
nts
1a.
Com
mu
nic
ate
wit
h m
edia
, th
e pu
blic
,
and
p
oli
cy
mak
ers
on
is
sues
o
f
scie
nti
fic
un
cert
ain
ty
1b. P
rovi
de e
xper
t te
stim
ony
on b
ehal
f of
pati
ents
an
d co
mm
un
itie
s
Spec
ialt
yCo
mpe
tenc
y IV
: Ris
kCo
mm
unic
atio
n,Ad
voca
cy, &
Eth
ics
Basi
cAd
vanc
ed
3. E
thic
s (u
nde
r de
velo
pmen
t)
Spec
ialt
yCo
mpe
tenc
y V:
Rep
orti
ngBa
sic
Adva
nced
Rep
orti
ng
1a.
Un
ders
tan
d i
mp
orta
nce
of
surv
eilla
nce
an
d i
nci
den
t
rep
orti
ng
1b.
Un
ders
tan
d ca
se r
epor
tin
g re
quir
emen
ts f
or p
esti
cide
exp
osu
res
1c.
Rep
ort c
once
rns
abou
t pes
tici
de e
xpos
ure
sit
uat
ion
s to
appr
opri
ate
auth
orit
ies
1a.
Stre
ngt
hen
ski
lls fr
om B
asic
com
pete
nci
es1a
.In
tera
ct w
ith
wo
rker
com
pen
sati
on
syst
em e
ffic
ien
tly
and
effe
ctiv
ely
Tabl
e 6
(con
tinu
ed)
48 DRAFT
Leg
isla
tive
an
d
Reg
ula
tory
Kn
owle
dge
1a.
Un
ders
tan
d th
at s
ever
al p
iece
s of
fed
eral
law
req
uir
e
hea
lth
car
e pr
ovid
ers
to a
ddre
ss p
esti
cide
poi
son
ings
1b.
Un
ders
tan
d th
at 1
5 st
ates
hav
e m
anda
tory
su
rvei
llan
ce
syst
ems,
an
d th
at 3
1 st
ates
hav
e so
me
form
of r
epor
tin
g
requ
irem
ents
1a.
Kn
ow
th
e sp
ecif
ic c
om
po
nen
ts o
f F
IFR
A,
OSH
A, T
OSC
A a
nd
WP
S th
at r
efer
ence
hea
lth
care
pro
vid
ers
1a.
Infl
uen
ce p
olic
y re
gard
ing
pes
tici
des
and
publ
ic h
ealt
h
Spec
ialt
y
Com
pete
ncy
VI:
Legi
slat
ive
and
Regu
lato
ryKn
owle
dge
Basi
cAd
vanc
ed
Tabl
e 6
(con
tinu
ed)
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EDUCATION COMPONENT C:
Assess Educational Settings
StatementConduct an assessment of the target audience of educational institutions to determine: (a)amount of existing coursework, (b) faculty members’ current knowledge and skill levels, andcomfort with teaching pesticide-related topics, and (c) how faculty and educational institutionswill best respond to educational programs and informational resources. This assessment willbe comprised of a literature review, surveys, and focus groups.
Expected OutcomesBaseline data indicating the level of education currently taking place in academic institutions,current curricular content and emphasis on pesticides/environmental health, currentknowledge of teaching faculty, and best mechanisms to reach and train faculty to teach.
Target AudienceAwareness and Motivation: This component targets academic institutions to determinetheir level of awareness; their level of interest in this topic; their knowledge and skills base;and the most effective ways to reach them through educational interventions, model programs,and resources.
Proposed ActivitiesActivity #1Conduct a literature review to locate survey data and evidence of level of training ineducational institutions.
Activity #2Where literature review is lacking in data, conduct a combination of audience assessmentactivities, including focus groups and interviews, to effectively collect baseline data and drawconclusions on the following questions:
J To what extent are the recognition and management of pesticide-related health conditionstaught in the targeted academic institutions?
J What is the extent of the knowledge, attitude, and skill base of faculty members withregard to pesticide issues? Are they at the stage of needing to raise awareness, improvetheir knowledge and skills, or provide them with resources?
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J What is the extent of faculty comfort level with teaching this topic area? What do facultyneed to feel more comfortable about teaching this topic?
J What resources, and in what format (e.g., traditional lecture material, teaching modules,Web-based, audio cassette, CD, videoconference, satellite), do academic institutions mostneed to teach about this topic?
Activity #3Produce a final report with recommendations for use in the development of the initiative.
Stakeholders
J Professional associations that represent academic institutions
J Academic institutions
J Faculty curriculum committees
J Faculty members
J Students
Evaluation of Outcomes/Indicators of Success
J Comprehensive literature search documenting the findings of studies that have surveyedacademic institutions and deans.
J Report with baseline data, conclusions, and recommendations.
BackgroundAny good plan has at its core a strong assessment component to collect baseline data on existingknowledge and skills, as well as to determine the most effective mechanism for reaching the targetpopulation. The importance of assessing educational institutions to determine what is already inplace, and how best to structure the educational interventions was emphasized by initiativeparticipants during the development of the Implementation Plan. This component will collectvital information not only for this initiative, but also for the entire field of health care providereducation. The assessment will also include a chance to determine where the target population“sits” along the continuum of change described in the section on Target Audience. Do most peoplelie at the beginning of the continuum where they will respond best to activities that raise theirawareness and motivate them to care about this issue? Or are they ready to make changes in theircurricula and are in need of tools and educational resources? The assessment will answer these,and other key questions, to inform the implementation process and subsequent evaluation.
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EDUCATION COMPONENT D:
Secure Official Endorsements
StatementEnsure the integration of the core competencies outlined in the National Guidelines intoeducational institutions by securing the official endorsements and support of key professionalorganizations and decision-making bodies.
Expected OutcomesProfessional organizations, licensing and accrediting bodies, administrators, and educatorswill agree that these competencies are essential to the education of primary care providersand will integrate or support their integration into core curricula.
Target AudienceAwareness and Motivation: This component targets key accrediting bodies and associationsfor academic institutions, along with academic deans and faculty committee chairs. Theemphasis here is on raising awareness and motivating decision-makers to bring about changein academic institutions that prepare health care providers.
Maintenance/Sustainability: This component also targets key professional associations toendorse and support the implementation and outcomes of this initiative over the long-term.The initiative will only be successful if its expected outcomes are institutionalized into theeducational settings for health care provider training.
Proposed ActivitiesActivity #1Promote competencies with professional and decision-making organizations and academicinstitutions (along with the case statement) through strategic meetings and outreach. Highlightthe specific recommendations in the National Guidelines on competencies, along with specificexamples of how an educational institution could integrate the content into curricula.
Activity #2Publish editorials in nationally recognized journals promoting the idea of integrating specificstrategies from the National Guidelines into curricula.
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Activity #3Develop a position paper on the need for competencies to be posted on the Internet, and foruse in meeting with decision-making bodies.
Activity #4Identify and promote incentives for faculty to teach core competencies, including financial incentivesin the form of grants, faculty development, curriculum development, and research, instructionalteaching and training aids, expert consultants, clinical access, release time for faculty development,curricula development, and establishing appropriate clinical sites and teaching venues.
Stakeholders
J Professional specialty organizations, licensing boards, accreditation/certification bodies
J National professional associations
Evaluation of Outcomes/Indicators of Success
J New position papers by targeted organizations that support the integration ofrecommended pesticide content into curriculum.
J New requirements by professional decision-making bodies that require institutions toteach about health effects from pesticides.
J Published journal articles in professional newsletters and peer-reviewed journals.
BackgroundThe success and sustainability of this initiative will only be achieved if the institutions themselvesfind ways to integrate pesticide-related content into health professional education. The bestmechanism to reach such organizations is for individuals involved in this initiative to meet one-on-one with key leaders and offer them simple and easy ways that they can endorse and/or adoptthis Implementation Plan.
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DRAFT
EDUCATION COMPONENT E:
1 While the organization and structure of academic health centers vary, every center comprises an allopathic and osteopathic schoolof medicine, at least one other health professional school or program, and one or more owned or affiliated teaching hospitals.
Strengthen and Build Faculty Champions
StatementCreate and support faculty champions within medical and nursing schools to teachenvironmental health and pesticide education in the curriculum, and to bring about changewithin their institutions. A champion, for purposes of this initiative, is defined as a facultymember who takes a leadership role in integrating environmental health and pesticides intohis/her institution in a sustainable fashion. This component is designed to ensure that astrong cadre of faculty champions is developed across the country who will lend expertiseand support for this effort in their institutions and surrounding communities.
Expected Outcomes
J Funding of 146 faculty champions, including one faculty champion in all 126 academichealth centers1 in the United States, plus an additional 20 faculty champions in 20 otherhigher education institutions to ensure a balance of medicine and nursing faculty as wellas representation from diverse institutions.
J Additional support for 10 of the academic health centers to serve as regional technicalassistance centers.
Target AudienceChampion Building: This component targets faculty members who are ready to become apart of a cadre of faculty from across the country who will teach courses, integratecompetencies into curriculum, and serve as a model for how to integrate environmentalhealth and pesticides into health professional education. The target audience is convinced ofthe importance of this issue and has enhanced its knowledge and skill level.
Proposed ActivitiesActivity #1Identify and select several model academic setting programs based on the existing work offaculty across the country, with specific focus on primary care faculty members. Hold a small
54
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DRAFT
invitational workshop of model programs and develop several models on which to base thefunding for all 146 academic institutions.
Activity #2Develop key required elements for a model faculty champion program including the following:
J Faculty member with 25% time availability.
J Faculty member trained in primary care (defined as pediatrics, family practice, internalmedicine, obstetric/gynecology, emergency medicine, or preventive medicine/public health).
J Commitment of staff time (part time health educator and administrative support).
J Existing and proposed partnerships within the academic health center to ensure that thefaculty champion’s work reaches all schools within the institution.
J Teaching and curriculum development component, including baseline analysis of studentknowledge and skills.
J Institutional change component with specific strategies articulated for changinginstitutions to support teaching environmental health/pesticides.
J Community-based sites for student practicum, internships, residencies.
J Advisory Committee, inclusive of environmental health expertise, curriculum committeemembers, community members.
J Opportunities to link teaching with research activities.
J Plan of action for 5-year integration.
J Evaluation component.
Activity #3Establish a coordinating body to manage the grant-making process, to convene the grantees,and to provide technical assistance to the faculty nationwide. Among the tasks of the nationalcoordinating office are to:
J Develop the RFA with the federal agencies; manage the application and grant-making processes.
J Produce a faculty guidebook with model programs on which faculty are asked to basetheir activities.
J Convene faculty for a working session to introduce model programs and work with projectdesign. Annual meetings will be held in subsequent years.
J Set up ongoing technical assistance and evaluation effort with faculty members to beavailable for the length of the project.
55 DRAFT
J Establish regular forms of communicationamong faculty members, including regionalmeetings, Web-based interactive activities,online submission of teaching modules orother curricular pieces, and formative andsummative evaluation.
J Present ongoing findings at nationalconferences and assist on national issues as theymay arise.
J Coordinate entire evaluation effort.
Activity #4
J Release RFA to academic institutions for a 5-year grant funded effort. Ensure diversity infaculty and disciplines selected. Publicize RFAprocess. Select 146 faculty champions.Applications must include all items listed inActivity #2 along with a timeline for completion.
J Incorporate a capacity-building mechanism into the grant-making process by creating10 regional networks of faculty members where the exchange of technical assistance cantake place. To achieve this, one academic center in each region would be granted additionalfunding (through a competitive process) to provide technical support to new facultychampions in that region. In this way, the program will help transfer knowledge andexpertise from existing champions to new faculty members, while also supporting theadditional time spent by existing champions.
Activity #5Launch initiative with the announcement of the 146 faculty champions and 10 regional centersreceiving additional funding. Faculty efforts will last 5 years with specific increments identifiedfor evaluation, workshops, submission of work, and activities via the Websites, and quarterly/annual reviews. Throughout the entire process, the national coordinating organization willbuild the cadre of faculty nationwide. (See Table 7).
Stakeholders
J Collaborating federal agencies
J Key association for health professional schools
J National coordinating body
“If we're going to make this successful, we
have to grow our own [champions], and
that takes some time.”— Candace Burns, PhD, ARNP
National Organization of Nurse Practitioners
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Evaluation of Outcomes/Indicators of SuccessThe entire component will be evaluated based on the following indicators:
Project Outcomes (1-5 year funded project)
J 146 institutions with documented integration of pesticides/environmental health intocurriculum.
J 146 institutions with increase in students’ basic knowledge and skills in pesticide/environmental health.
J 146 institutions with increased FTE time devoted to environmental health.
J Increase in number of practice/field experiences in environmental health sites
J Increase in environmental health research activities.
Project Outcomes (post 5-year project)
J Increase in new researchers investigating environmental health.
J Increase in number of primary care providers out of the pipeline who address environmentalhealth in practice and research.
amay be subcontracted by the national coordinating organization.
Institution Funded Activities Funded Individuals Funded Length of Funding
National Overall coordination Project Director, 6 years (design,Coordinating and management (100% FTE), Coordinator implementationOrganization of project and (100% FTE), Webmaster and evaluation)
administrative staff
10 regional centers Existing faculty Faculty Champion (50% FTE), 5 year grant period(one per EPA region, champion support plus Regional Coordinatorchosen from academic technical assistance (50% FTE),health centers) support for faculty administrative staff
in the region
146 academic sites Implementation of Faculty champion (25% FTE), 5 year grant period(126 academic health one of several models administrative supporthealth centers + 20 in academic institutions,representing diverse including inclusionpopulations and in curriculum, andnursing schools) institutional change
Evaluation Teama Formative and Evaluation staff Portions of all 6 yearssummative evaluation
Table 7: Proposed Design of Faculty Champions Project
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J Sustainable institutional change in majority of 146 institutions.
J Changes in the way health professionals address environmental health (measure of overalleffectiveness).
BackgroundThis component proposes a significant investment of funding to build a strong cadre of facultychampions. The funding would pay for part of a designated faculty FTE, plus a half-timeposition for administrative and content support at 146 institutions. The funding would alsosupport 10 regional centers headed by an existing faculty champion and designed to providetechnical assistance and support to new faculty members in the region. The champion woulduse a variety of educational methodologies (required courses, integration within existingcourses, field experience, and links with community members and organizations), and wouldlink with other schools, departments, and organizations as part of a national network ofchampions. In particular, it is recommended that faculty champions coordinate with modelpractice sites (see Practice Component E, p. 75). The intent is for the faculty champion tobase his/her activities on selected model programs that have already undergone evaluation.
The idea of creating and strengthening “champions” of pesticide/environmental healtheducation came out of the Education Workgroup’s discussion of how important a roleindividuals can play at an institution. A threshold level of funding and security of funding isneeded to encourage institutions to hire and/or nuture pesticide/environmental healthchampions. A multi-year commitment is also necessary to make it worthwhile both for theinstitution and the champion. Much of the champion’s time should be spent institutionalizingthe pesticide/environmental health component by developing faculty interest/knowledge andintegrating it into curriculum, both in medicine and nursing disciplines. Otherwise, whenthe grant funding ends, the environmental health/pesticide component is likely to be viewedas “nice but not necessary” and may disappear at the next curriculum change cycle. The proposaldeveloped is for five year funding, with funding possibly decreasing in years 3-5.
It is recommended that all academic health centers receive funding at the same time. It isimportant to make the funding equal across academic health centers. This component willfund 126 academic health centers and an additional 20 institutions to ensure a balance betweenmedicine and nursing, and the inclusion of diverse institutions. Faculty champions will beselected equally from the disciplines of medicine and nursing. Faculty champions will also beselected from primary care. Given that some institutions already have faculty champions, theproject will include an opportunity for such institutions to compete for regional center grants.The regional centers will be required to provide technical assistance and support to new facultychampions in the region. The entire project will build upon other faculty champion modelsthat have been created for other subject areas nationwide.
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DRAFT
EDUCATION COMPONENT F:
Create Teaching IncentivesStrategyInfluence the appropriate boards, organizations, and institutions that create Board examsand set curriculum requirements to include several key competencies on pesticides andenvironmental health.
Expected Outcomes
J Questions on Board exams
J Changes in curriculum requirements
Target AudienceAwareness and Motivation: This component targets decision-making organizations thatset curriculum requirements, entities that write Board and certification examinations,and faculty who teach based on requirements and exams. This component is designed tomotivate and convince these decision-makers to integrate into their requirements andexams small components that address the health effects from pesticide exposures. Thiscomponent will also provide “ready-made” language on requirements and/or examobjectives and questions.
Proposed ActivitiesActivity#1Conduct an initial assessment to determine number of questions related to pesticides/environmental health on examinations. Identify or develop sample examination questions.The assessment will also list timeframes for changes in requirements/Board exam questionsby key decision-making bodies.
Activity #2Develop a succinct strategy for approaching the organizations/decision-making bodies thatdevelop Board and other examinations, including specific recommendations for educationalobjectives, questions and language changes. Action items include:
J Convene a working group of high level external partners and key federal agencies to developstrategy/position paper. This group should be drawn from the Association of AmericanMedical Colleges, the American Association of Colleges of Nursing, the American
59
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Association of Occupational Health Nurses, the American College of Occupational andEnvironmental Medicine, the American Medical Association, the American NursesAssociation, the American Association of Physical Assistants, and American College ofNurse Midwives. In addition, federal agencies could include National Institute ofEnvironmental Health Sciences, National Institute of Occupational Safety and Health,EPA, and Health Resources and Services Administration.
J Create a strategy that recommends specific content (per National Competency Guidelinesin Education Component B) and insertion points into specific Board exams and specialtyrequirements. Strategy will also set targets for change.
Activity #3Contact decision-making bodies and provide with them with specifically tailored positionpaper and recommended changes to questions, exams, and requirements. Include theendorsement of the relevant working group organizations. Identify Boards and schedule usingthe following outline of priorities:
Short-term PrioritiesMedicine:
J United States Medical License Examination (Steps 1, 2, 3)
J Board Examinations in Family Practice, Pediatrics, Internal Medicine, Ob/Gyn,Emergency Medicine
Nursing:
J AANC generalist examinations
J Nurse practitioners — adult, pediatrics, family, gerontological (ANP, PNP, FNP, GNP)
J Nurse midwives — American College of Nurse Midwives (ACNM)
J Clinical nurse specialists (CNS)
Longer-term Priorities
J Physicians Assistants
J Pharmacists
J Basic Nursing
J Genetic Counselors
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StakeholdersJ Key national decision-making bodies for curriculum changes, requirements, and
examinations
J National professional association
J Key federal agencies involved with health profession education
J Faculty members
Evaluation of Outcomes/Indicators of Success
J Increase in the number of questions in the examination pool and on each examination ascompared with the initial assessment.
J Changes in requirements for primary care disciplines (pediatrics, family practice, internalmedicine, preventive medicine/public health, emergency medicine and obstetrics andgynecology) to include pesticides/environmental health.
BackgroundOne way to motivate change in curriculum is to convince the medical and nursing examinationboards of the importance of environmental health in the coming years, and urge them toincorporate environmental health questions on their exams. This would also be one of the betterways to institutionalize the subject matter over the long term. Some of the boards are expectedto be receptive to a concerted effort in this area; for example, the Residency Review Committeefor Pediatrics in 1997 adopted two recommendations on children’s environmental health.
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Practice Settings
The second prong of the strategy is the practice setting. Practice settings, for purposes ofthis initiative, are defined as community health centers and clinics; managed care clinics;hospitals and emergency departments; private practices; urgent care centers; poison control
centers; and work and/or school-based clinics. While the components target the practice setting,they also involve the professional associations and decision-making bodies that represent and/or influence the practice setting. These include, for example, the American Nurses Association,the American Academy of Pediatrics, the American Academy of Family Physicians, and theMigrant Clinicians Network, to name a few. The following components cut across the continuumof systemic change — from raising awareness and assessment, to development of expected practiceskills, to the support of “model practices” and system-wide incentives.
Component A: Make the case for practitioners — Develop an effective case statement to convinceprimary care providers of the need to incorporate environmental health and pesticide awarenessinto their practice settings.
Component B: Define practice skills and guidelines — Produce National Guidelines thatrecommend practice behaviors and guidelines for the recognition, management, andprevention of pesticide exposures, for all practicing health care providers; define accompanyingcontent related to expected behavior; suggest methods of integration into practice and trainingsettings; and provide access to relevant resource materials.
Component C: Assess knowledge and skills of practitioners — Conduct an assessment ofthe target audience of primary care providers to determine: (a) providers’ current knowledgeand (b) how providers will best respond to educational programs and informational resources.This assessment will be comprised of a literature review, surveys, and focus groups.
Component D: Secure official endorsements — Ensure the integration of the expected practiceskills into practice settings by securing the official endorsements of key professionalorganizations and decision-making bodies specific to practice.
Component E: Demonstrate model programs — Mobilize practice settings to becomepopulation-specific and to incorporate environmental considerations (specifically pesticides)into prevention, education, diagnosis, and treatment. Achieve incremental, site-specificimprovements in identification, early intervention, and prevention, as well as in measures ofpractice-specific health outcomes. By 2010, half of all primary health care practice settings in
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PR
AC
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DRAFT
the United States should incorporate environmental considerations in prevention, education,management, and referral.
Component F: Create incentives for change — Identify and promote a number of incentivesto incorporate appropriate prevention, recognition, and management of pesticide-relatedhealth conditions into health care practices. Specifically: (1) provide grant support to practicingproviders for interventions and research related to pesticide poisonings and exposures, (2)create free, readily available opportunities for continuing medical education involvingpesticides and environmental health, (3) increase providers’ awareness of the value of takingan occupational and environmental history for optimizing Evaluation and Management(E&M) coding and billing, (4) require knowledge of environmental health issues forcertification and recertification, (5) require pesticide poisoning reporting for workercompensation reimbursement and automatic worker compensation reimbursement for work-up of suspected occupational pesticide-related health conditions, and (6) promotedocumentation of occupational and environmental history in medical records viaincorporation into quality assurance/quality control mechanisms.
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AC
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DRAFT
PRACTICE COMPONENT A:
Make the Case for Practitioners
StatementDevelop an effective case statement to convince primary care providers of the need toincorporate environmental health and pesticide awareness into their practice settings.
Expected Outcomes
J A written case statement that documents the key points of why practicing health careproviders should care about the environments in which their patients live, especially withregards to potential pesticide poisonings and exposures, along with the accompanyingscientific literature to support the need for well educated health care providers. Thisstatement will be linked with the case statement for educational settings.
J Endorsement of the case statement by leading national professional associations andnational bodies that work with practitioners.
Target AudienceAwareness and Motivation: This component is targeted at decision-makers and key strategicorganizations that need to be convinced that the issue of pesticide poisonings and the need toeducate health care providers about this issue are relevant to the practice settings of healthcare providers. This component also targets primary care providers who are not yet convincedthat this is an appropriate subject for a national plan.
Proposed ActivitiesActivity #1Research and develop a case statement, solicit peer review, and finalize with the input of keystakeholder groups in the field. The target audience for the case statement is the practicinghealth care providers and the organizations that work with them.
Points to be covered in the case statement:
J Importance of environmental health training and the breadth of the problem of pesticide-related health conditions.
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J Convincing arguments for why pesticides should be part of what health care providersaddress in their practice settings, with cited scientific data, along with relevance to thepractice of health care and public health.
J Compelling arguments to gain the attention of primary care providers despite the factthat their time and attention are in high demand elsewhere.
J Emphasis that practitioners do not need to become experts, and reassurance that expertsare available to work with them on specific clinical cases and/or community concerns.
J Reassurance that user-friendly tools exist for practitioners to use, along with user-friendlyguides for teaching pesticide issues to practitioners through continuing education.
J Recommended amount of time to dedicate to pesticides in the clinic that is reasonablegiven the other demands on practice settings.
Activity #2Promote case statement through effective dissemination mechanisms, including print andInternet information sources.
Activity #3Publish journal or newsletter articles in professional journals and publications.
Activity #4Hold strategic meetings with professional associations and national leaders to seek theirendorsement of the case statement. This includes identifying a subset of decision-makerswho can be influenced by the case statement.
Stakeholders
J Professional associations
J Recertification bodies
J Continuing education organizations
Evaluation of Outcomes/Indicators of Success
J Case statement
J Published articles in professional journals and newsletters
J Position papers developed and adopted by professional associations
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BackgroundIt is recognized that many key decision-makers are still unconvinced that this is an issue ofconcern. Although the supporting documentation exists, there is a need to pull the informationtogether in a succinct case statement directly designed for practitioners.
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PRACTICE COMPONENT B:
Define Practice Skills and Guidelines
StatementProduce National Guidelines that recommend practice skills and guidelines for the recognition,management, and prevention of pesticide exposures, for all practicing health care providers;define accompanying content related to expected behavior; suggest methods of integration intopractice and training settings; and provide access to relevant resource materials.
Expected Outcomes
J National Pesticide Practice Skill Guidelines which recommend practice skills, content,insertion points into practice and training settings, and resources. The Guidelines will becompleted in mid-2000.
J Endorsement of National Guidelines by leading national professional associations.
Target AudienceReadiness to Change: This component is targeted at administrators of clinics and healthcare delivery systems, providers of professional development, and practitioners. Thecomponent assumes that the administrators and practitioners are convinced of the importanceof this topic and are ready to make changes in their practices.
Proposed ActivitiesActivity #1Define the basic practice skills for practice settings to ensure that all practicing primary care providersare prepared to address pesticide-related health conditions and exposures in their practice.
A preliminary outline of practice skills for practicing health care providers has already beencompleted, as shown in Table 8 on page 68. The intent of the table is to define expectedpractice skills for all practitioners. This table will link with a complementary document beingcreated for educational settings.
Activity #2Produce National Guidelines that will guide practitioners on the recognition and managementof pesticide-related health conditions. A complementary report will focus on the educationalsettings where primary care providers receive their training.
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The National Guidelines will be drafted by a team of experts and will contain the followingcomponents:
J Recommended practice skills.
J Relevant content for each practice skill.
J Suggested points of insertion into practice settings.
J Suggested resources to teach content specific to each competency in practice settings.
The team will be responsible for meeting the following objectives:
1) Define the target population for the practice setting for purposes of this project.
2) Qualitatively analyze the existing content in the practice settings for both physicians andnurses, and identify relevance to pesticide expected practice skills. (The team is expectedto conduct a literature review, but not to conduct a full survey and/or questionnaire ofexisting content.)
3) Identify new content to be added to practice settings for each expected practice skill.
4) Determine windows of opportunity for inserting the content into existing trainingprograms (including continuing education, distance learning, etc.), for physicians andnursing. Develop a map of creative delivery mechanisms highlighting potential points ofinsertion of pesticide-related content in such training programs.
5) Identify resources specific to each expected practice skill that can be added to acomputerized database of educational resources.
6) Develop recommendations for designing and implementing workshops and educationalopportunities with professional associations and continuing education.
The report will be designed as a user-friendly guide on how to integrate pesticides contentinto practice skills. It will serve as a supplementary practitioner guide to the Recognition andManagement of Pesticide Poisonings. The report will not contain actual training modules orresources, but instead will provide a listing of relevant resources and how to locate them.
Activity #3Promote the National Guidelines with key stakeholders and solicit official endorsements andorganizational support of report, including dissemination to their members.
Stakeholders
J National professional associations for practicing primary care providers
J Practicing health care providers who have already developed tools and practice models
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Evaluation of Outcomes/Indicators of Success
J The National Guidelines will include defined practice behaviors, content areas, insertionpoints, examples as necessary, and recommended resources.
J Endorsement by key professional organizations for providers.
BackgroundThe preliminary list of “Expected Practice Skills” shown in Table 8 is recommended as a usefulgoal for primary care providers seeking to provide the highest quality care to their patients.This list will form the starting point for future efforts.
1. Take an environmental and occupational health history.
J Providers should be able to take a basic environmental and occupational historyto determine if a temporal relationship exists between exposure and symptoms.
J Ask patients 2-3 screening questions that would elicit possible exposure to anumber of environmental factors (including but not limited to pesticides).
J Take an environmental health history with questions regarding where the patientlives, works, and plays.
2. Recognize the signs and symptoms of pesticide exposures and appropriatelymanage or refer patients.
J Recognize the signs and symptoms of pesticide exposures (both acute and chronic).
J Providers should be able to treat and manage health conditions associated withpesticide exposure or refer patients to appropriate specialists and resources, andfollow up appropriately.
J Diagnose pesticide-related health conditions using appropriate testing proceduresand treat pesticide exposures.
3. Identify risk factors for pesticide exposure and resulting health effects.
J Identify risk factors for pesticide exposure (e.g. occupation, location of home,susceptible populations such as children).
Table 8: Expected Practice Skills — Preliminary Outline
— continued on the following page
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Table 8 (continued)
J Identify environmental factors that may possibly be linked to patient illness toensure that chronic pesticide exposures are addressed.
4. Demonstrate key principles of environmental/occupational health andepidemiology and population-based health.
J Demonstrate an understanding of principles of environmental and occupationalhealth, and epidemiology.
J Understand the temporal relationship between exposure and symptoms.
J Recognize that others may be ill (co-workers, family) and get a timeline of healthproblems for these or consult public health authorities for help in evaluating exposures.
5. Take steps to report pesticide exposure and support surveillance efforts.
J Understand the importance of surveillance and reporting.
J Be able to access and report data for local, regional, and national surveillance programs.
J Report cases involving pesticide exposures as required.
J Report concerns about pesticide exposures to the appropriate authorities, such aslocal and state health departments, NIOSH, OSHA or state departments of labor,or departments of agriculture.
6. Possess basic awareness of communities in which patients live.
J Providers should possess a basic awareness of environments in which patients live,work, and play in order to anticipate possible encounters with exposure to pesticides.
J Demonstrate an understanding of population-based health.
J Demonstrate knowledge about the environment in which the practice is situated, withspecific understanding of communities that may be at-risk for pesticide exposures.
J Be aware of, and access, the resources available within the community and in thestate or region, that could assist in pesticide exposures and illness.
7. Provide prevention guidance/education to patients.
J Provide guidance to patients on how to prevent pesticide exposures.
J Advise patients and provide basic education about pesticide exposure.
J Counsel patients about minimizing unnecessary use of pesticides, refer patientsto appropriate experts on integrated pest management.
J Address the whole patient in the context of his/her life and/or community (e.g.,link to social services, etc.).
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PRACTICE COMPONENT C:
Assess Knowledge and Skills of Practitioners
StatementConduct an assessment of the target audience of primary care providers to determine: (a)providers’ current knowledge and (b) how providers will best respond to educational programsand informational resources. This assessment will be comprised of a literature review, surveys,and focus groups.
Expected OutcomesBaseline data indicating the level of training currently taking place in practice settings, currentknowledge of practicing providers, and identification of best mechanisms to reach and trainproviders, and to equip them with user-friendly tools.
Target AudienceAwareness and Motivation: This strategy targets health care practitioners to determinetheir level of awareness; their motivation, or lack of motivation, for this topic; their knowledgeand skills base; and the most effective ways to reach them through educational interventions,model programs, and resources.
Proposed ActivitiesActivity #1Conduct a literature review to locate survey data and evidence of level of knowledge, attitudeand skills of health care providers related to pesticide-related health conditions.
Activity #2Where literature review is lacking in data, conduct a combination of audience assessmentactivities, including surveys and focus groups, to be able to effectively collect baseline dataand draw conclusions on the following questions:
J To what extent are the recognition and management of pesticide-related health conditionsincluded in the continuing professional development of primary care providers?
J What is the extent of the knowledge, attitude, and skill base of practicing primary careproviders with regard to pesticide issues? Are they at the stage of needing to raise awareness,improve their knowledge and skills, or obtain resources?
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what [resources] health care
providers want and need.”— Allen James, MBA, CAE
Responsible Industry for a Sound Environment
J What level of comfort do practitioners have withaddressing pesticides with their patients and incommunities? What do practitioners need to feelmore comfortable in addressing pesticides intheir practice settings?
J What resources, and in what format (e.g.,traditional lecture material, teaching modules,Web-based, audio cassette, CD, videoconference,satellite), do practitioners need most?
Activity #3Produce a final report with recommendations for usein the development of the initiative.
Stakeholders
J Professional associations that representpractitioners
J Continuing education programs, organizationsthat offer continuing education
J Practicing clinics and health care delivery systems
J Practicing providers
Evaluation of Outcomes/Indicators of Success
J Comprehensive literature search documenting the findings of studies that have surveyedpracticing primary care providers.
J Report with baseline data and conclusions/recommendations for implementation ofthe Initiative.
BackgroundAny good plan has at its core a strong assessment component to collect baseline data onexisting knowledge and skills, as well as to determine the most effective mechanism forreaching the target population. This component will collect vital information not onlyfor this initiative, but also for the entire field of health care provider education. Theassessment will also include a chance to determine where the target population presents
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itself along the continuum of change described in the section on Target Audience. Domost people lie at the beginning of the continuum where they will respond best to activitiesthat raise their awareness and motivate them to care about this issue? Or are they ready tomake changes in their practice and are in need of tools and educational resources? Theassessment will answer these, and other key questions, to inform the implementationprocess and subsequent evaluation.
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PRACTICE COMPONENT D:
Secure Official Endorsements
StatementEnsure the integration of the expected practice skills into practice settings by securing theofficial endorsements of key professional organizations and decision-making bodies.
Expected OutcomesProfessional organizations, influencing bodies, and practitioners will agree that the expectedpractice skills are essential to the ongoing training of primary care providers and will integrateor support their integration into practice settings.
Target AudienceAwareness and Motivation: This component targets key recertification and continuingeducation bodies and professional associations for practitioners. The key emphasis here is onraising awareness and motivating decision-makers to bring about change in practice thatprovide lifelong learning to health care providers.
Maintenance/Sustainability: This component also targets key professional associations toendorse and support the implementation and outcomes of this initiative over the long-term.This initiative will only be successful if its expected outcomes are institutionalized into thepractice settings for health care provider training.
Proposed ActivitiesActivity #1Promote expected practice skills and case statement with professional organizations to garnertheir involvement and support in implementing interventions to improve the knowledge,attitudes, and skills of practicing health care providers.
Activity #2Highlight the specific recommendations in the National Guidelines on expected practice skills,along with specific examples of how practice settings can integrate the content into the ongoingtraining of providers.
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Activity #3Publish editorials in nationally recognized journals on specific strategies from the NationalGuidelines, along with user-friendly tools for providers.
Activity #4Develop a position paper on the need for expected practice skills, to be posted on the Internetand for use in meeting with credentialing bodies and decision-makers.
Activity #5Identify and promote incentives for professional associations to be involved in the initiative,including financial incentives in the form of grants, technical assistance for clinics, community-based interventions and research, instructional teaching and training aids, expert consultants,clinical access, release time for professional development, and establishing appropriate clinicalsites for additional training.
StakeholdersJ Professional specialty organizations
J Licensing boards
J National professional associations
Evaluation of Outcomes/Indicators of SuccessJ New position papers by targeted organizations that support the integration of
recommended pesticide content into practice settings.
J New requirements by professional decision-making bodies that require professionaleducation to teach about health effects from pesticides.
J Published journal articles in professional newsletters and peer-reviewed journals.
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PRACTICE COMPONENT E:
Demonstrate Model Programs
StatementMobilize practice settings to become population-specific and to incorporate environmentalconsiderations (specifically pesticides) into prevention, education, diagnosis, and treatment.Achieve incremental, site-specific improvements in identification, early intervention, andprevention, as well as in measures of practice-specific health outcomes. By 2010, half of allprimary health care practice settings in the United States should incorporate environmentalconsiderations in prevention, education, management, and referral of pesticide-relatedhealth conditions.
Expected Outcomes
J Demonstration projects (distributed geographically across the United States) that modelpractice settings where pesticide-related health conditions are an integrated part of theprovision of care and community outreach.
J Evaluation of demonstration models and creation of a “models that work” guide for thefield and other practice settings.
J Creation of a tool kit that can be used by other practice settings that want to set up amodel program.
J Launching of nationwide effort to redesign 50% of all practice settings.
Target AudienceMaintenance/Demonstration: This component targets specific practice settings that areready to become part of a cadre of model practices across the country that will change theway they practice, specifically addressing potential health effects from pesticide poisoningsand exposures. The target audience in this case has been convinced that this is an importantissue and has increased its knowledge and skills in this area. Model practices may also belocated in areas of higher impact, such as farmworker clinics and urban settings.
Proposed ActivitiesActivity #1Mobilize practice settings that currently address environmental health/pesticide issues. Identify currentleaders among practice settings and encourage them to spread the word on what they already do.
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Activity #2 (option 1)Secure funding, create a program description, and develop an RFP to solicit proposals from 5-10 clinical/community sites to receive financial support over three years to create a practicemodel. Ensure that the funded sites represent the range of practice settings and the breadth ofpesticide issues (e.g., urban and rural, agricultural and non-agricultural, diversity of culturesand literacy rates). Ensure that some programs are located in states with pesticide reportingrequirements.
Activity #2 (option 2)Secure funding, create a program description, and develop an RFP to solicit small proposalsfrom 100 clinical/community sites to receive financial support over 1.5 years to create a practicemodel. Ensure that the funded sites represent the range of practice settings and the breadth ofpesticide issues (e.g., urban and rural, agricultural and non-agricultural, diversity of culturesand literacy rates). Ensure that some programs are located in states with pesticide reportingrequirements.
Activity #3Define the major components of the proposed practice model, allowing for flexibility by thespecific site. Ensure that the models are grounded in theories and experience about how changeactually happens so as to learn from other experiences in practice settings. One model thathas been recommended is the Diabetes Collaborative (see box on page 78).
Activity #4Establish a coordinating body to manage the project and the creation of the consortium ofpilot sites, and to create the plan of action for the project. Among the tasks of the nationalcoordinator are:
J Create a consortium of the pilot sites that use the proposed model as a guide for developingtheir own specific practice intervention plan (including what they want to do, theintervention, the evaluation and the implementation of the proven change).
J Build a technical assistance component that can work with sites in designing theintervention, piloting the intervention and evaluating its success.
J Convene pilot sites on a regular basis by conference call and in-person meetings to sharesuccess stories, challenges, and lessons learned.
J Establish an evaluation mechanism for the sites and the national project to determine thesuccess of the creation of new models. Evaluation would be both formative and summative.
Activity #5Launch nationwide effort to redesign 50% of practice settings based on findings from themodel sites.
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StakeholdersJ Professional associations
J Practice settings
J National coordinating organization
J Funding agencies and partners
J Organizations that have created practice change models
Evaluation of Outcomes/Indicators of SuccessJ RFP completed and funding secured for pilot program.
J Chosen sites underway in developing practice models.
J Five to ten practice change models with evaluation components and identified success stories.
J Publication of model programs.
J Effective dissemination of practice models nationwide.
J Enhanced reporting of cases.
BackgroundThe key to changing practice is demonstrating how changes in day-to-day activities actuallymake a difference in health outcomes of patients and communities. This strategy was generatedby the Practice Workgroup as a way to model expected changes and to evaluate what practicechanges actually lead to the overall goal of the initiative — to increase the recognition,management and prevention of pesticide poisonings and exposures. There are two recommendedoptions for this strategies: (1) fund a large number of demonstration practice sites to makeseveral small practice changes and evaluate the outcome, or (2) fund a small number ofdemonstration practice sites to overhaul their practices and bring about substantial change.Both options offer different rewards and utilize the resources in different ways. In either case,there are model organizations that have developed such an effort for other health conditions,such as the Diabetes Collaborative (see box on page 78).
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VEThe Diabetes Collaborative is a multi-year initiative sponsored by the Health Resources
Services Administration and the Bureau of Primary Health Care, in partnership with health
centers, primary care associations, and clinical networks. Its goal is to eliminate health
disparities and ensure access to quality primary care for racial and ethnic minorities and
for underserved populations. Among underserved and minority populations, diabetes is a
virtual epidemic, with 1.2 million patient visits in 1996 alone, and lost resources and human
productivity estimated at over $92 billion annually.
The project aims to redesign diabetes management to effect a measurable change in health
status among the approximately 60,000 diabetic patients at the 92 participating health
centers. The key concept of the partnership is dissemination of the lessons learned through
adapting the learning process developed by the Institute for Healthcare Improvement. The
project was developed as part of the Breakthrough Series Workgroup of the Clinicians
National Forum.
The improvement model is based on three fundamental questions: (1) What are we
trying to accomplish? (2) How will we know that a change is an improvement? and (3)
What changes can we make that will result in an improvement? The national measure
of success for the first phase of the project is meeting the goal of over 90% of the 60,000
diabetic patients in the target population receiving two HbA1c blood tests per year, at
least three months apart. A short-term trial-and-learning method called PISA (Plan,
Do, Study, Act) provides the framework for implementing changes and learning from
them. An example of PISA in action might be:
J Plan: The diabetes team at Rocky Road Health Center predicted that a registry of diabetic
patients would improve the measurement of HbA1c. Setting up this system took 3
weeks. During that time, the center also established protocols for glucose measurements
and ran a trial utilizing patient self-management for home glucose measurements.
J Do: The registry was tested for 2 weeks with one volunteer nurse practitioner and
her diabetic patients. After the diabetes flow sheet was revised to reflect the registry
information, the collection went well.
J Study: The time spent on completing the flow sheet increased from 1 minute to 2
minutes and it took an additional 3 minutes to enter data into the registry. Waiting
time for diabetic patients increased an average of 8 minutes. Of the patients with
diabetes, only half had appropriate testing of HbA1c; but after the trial, all of the
patients had current values.
J Act: After a team meeting with the executive director and finance officer in charge
of the information system, the health center adapted a scannable flow sheet form
they had learned about from the Midwest Clinicians Network. To cut down on
cycle time, the medical records were reviewed the night before to identify gaps and
pre-enter data.
Source: Migrant Clinicians Network
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PRACTICE COMPONENT F:
Create Incentives for Change
StatementIdentify and promote a number of incentives to incorporate appropriate prevention,recognition, and management of pesticide-related health conditions into health care practices.Specifically, (1) provide grant funding to practicing providers for interventions and researchrelated to pesticide poisonings and exposures, (2) create free and readily available opportunitiesfor continuing education involving pesticides and environmental health, (3) increase providers’awareness of the value of taking an occupational and environmental history for optimizingEvaluation and Management (E&M) coding and billing, (4) require knowledge ofenvironmental health issues for certification and re-certification, (5) require pesticidepoisoning reporting for worker compensation reimbursement and automatic workerscompensation reimbursement for work-up of suspected occupational pesticide-related healthconditions, and (6) promote documentation of occupational and environmental history inmedical records, via incorporation into quality assurance/quality control mechanisms.
Expected Outcomes
J Increased attention paid by primary care providers to pesticide poisoning and exposuresbased on incentives to change practice.
J Creation of new or improved incentives in the following areas: monetary incentives,legal incentives, community-based incentives, and peer/professional incentives.
Target AudienceAwareness and Motivation: This component targets health care system administrators andfunders to create incentives for providers to address pesticide-related health conditions. Thiscomponent is designed to motivate and convince decision-makers that specific changes canand should be made in grant funding, continuing education, E&M codes, re-certification,workers compensation, and quality assurance. This component will also provide “ready-made”language on recommendations for proposed changes.
Proposed ActivitiesActivity #1Provide grant support to practicing providers for interventions and research related to pesticidepoisonings and exposures:
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J Urge federal agencies (CDC, NIH, EPA, HRSA), state agencies, and private foundationsto support intervention and research projects conducted by practicing primary careproviders.
J Publicize models developed through grant support.
J Create a centralized source of information about grants and grantees.
Activity #2Create free and readily available opportunities for continuing education involving pesticidesand environmental health:
J Connect continuing education (CE) courses on pesticides to major national meetings.
J Offer free CE credits in a variety of settings.
J Offer CE credits in local settings and support experts to go out to local clinics to providepesticide education.
J Establish free, Web-based continuing education.
J Encourage and fund NIOSH Education and Research Centers (ERCs) to hold localcontinuing education courses on pesticides.
J Address barriers such as competing priorities for providers, cost of hosting continuingeducation programs, and lack of provider interest.
Activity #3Increase providers’ awareness of the value of taking an occupational and environmental historyfor optimizing Evaluation and Management (E&M) coding and billing. See next page for abrief summary of how E&M coding could be upgraded.
Activity #4Require knowledge of environmental health issues for certification and re-certification:
J Identify priority professional certifying bodies.
J Recruit high-profile supporters from each of the relevant disciplines.
J Create sample objectives and questions on environmental health issues.
J Approach certifying bodies about including questions.
J Coordinate outreach to the certifying bodies.
J Address barriers such as institutional inertia, competing priorities, and lack ofperceived problem.
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Activity #5Require pesticide poisoning reporting for worker compensation reimbursement andautomatic worker compensation reimbursement for work-up of suspected occupationalpesticide poisoning. See, for example, Washington State’s program described on page 82.The goals are for work-related pesticide health effects to be universally reimbursed,including relevant diagnostic testing; mandatory reporting of pesticide-related healtheffects for worker compensation reimbursement; and standardized weight-of-evidencefor claims reimbursement for pesticide-related illnesses. Tasks include:
J Target high-priority states for change.
J Gather information about model state worker compensation laws (especially Californiaand Washington).
J Win support of professional organizations, advocacy groups, and state agencies.
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GAccording to the 1997 Health Care Financing Administration DocumentationGuidelines, in order for a provider to bill for a “comprehensive” visit for a newoutpatient, a new inpatient, or a new consult, the provider must document takingall of the following: a past medical history (PMH), a family history (FH), and asocial history (SH). The social history is defined as an “age-appropriate review ofpast and current activities.” For follow-up visits and emergency department visitsto be designated as comprehensive, two out of the three histories must bedocumented. It may be possible to convince health care providers that taking anoccupational/environmental medicine history will help them to fulfill the SHrequirement for billing for a “comprehensive” visit, particularly for new patients.
The billing codes affected are:
J New outpatient visit codes 99204 and 99205
J New outpatient consults 99244 and 99245
J New inpatient consults 99254 and 99255
J Initial hospital care 99222 and 99223
J Emergency department 99285
These HCFA Documentation Guidelines apply only to Medicare patients;however, most third-party payers have adopted the same guidelines for theirreimbursement schedules. Considerable research will need to be done todetermine if this approach is viable.
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Washington State has moved into the forefront in reporting of occupational diseases.Under state law, the Department of Labor and Industries (L&I) and the Departmentof Health (DOH) both have responsibilities for addressing chemically-related illnesses(CRI)—illnesses known or suspected to be caused or substantially worsened byexposure to chemicals in the workplace or other environments.
To increase efficiency and provide more consistent handling of chemically-relatedclaims, L&I established a single CRI unit with responsibility for all chemically-related claims. Claims adjudicators in the CRI unit receive special training onchemically-related injuries and illnesses. L&I has also contracted with anoccupational medicine physician to provide additional medical review of the morecomplex claims and to ensure that appropriate testing and work-ups are done.L&I averages about 200 claims per month.
Some of the key provisions of Washington’s worker compensation system include:
J An injury/illness incident is eligible for a claim to be filed whenever medicaltreatment is provided.
J For all claims filed, the costs for diagnostic evaluations to determine if the injury/illness is work-related are covered. Although the claim may eventually be rejected ifit is determined not to be work-related, the initial visit(s) and testing are paid for.
J Individuals with accepted claims are eligible for time loss (wage replacement) ifthey lose more than 3 days of work.
J Health care providers are required to file a claim if the worker feels the conditionis work-related.
The CRI unit has recently started to identify clusters of chemically-related illnesses,particularly involving a single employer with more than one claim for a specificexposure event. The goals include early intervention to reduce exposures and preventfuture morbidity and mortality. For example, a cluster of carbon monoxide poisoningswas identified, triggering efforts to reduce future exposures in the plant where thepoisonings occurred. CRI staff find this process also improves the adjudication ofclaims by grouping together the claims from a particular employer.
Since 1990, DOH has been responsible for investigating pesticide-related illnessincidents and developing a database of pesticide-related problems. L&I providesdetailed reports to DOH to enable DOH to include worker compensation claims intheir investigations. Some consider the claims process to fulfill their reportingrequirements, although there is a longer delay when L&I reports claims to DOHthan when a health care provider reports directly to DOH at the time a patient isevaluated. It is not clear if this mechanism is sufficient or could be improved.
Source: Mary Miller, Washington State Department of Labor and Industries
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J Approach state Workers Compensation Commissions for changes.
J Build key leadership supporters including worker compensation attorneys, labor,farmworker groups, clinicians, and public health groups.
J Address barriers such as lack of leadership, cost, and decentralized state authorities.
Activity #6Promote documentation of occupational and environmental history in medical records, viaincorporation into quality assurance/quality control mechanisms. Quality Assurance/QualityControl mechanisms could also be used to promote documentation that providers have givenpesticide information to certain at-risk groups (e.g., parents of toddlers, farmworkers, pregnantwomen). Activities include:
J Create respected consensus on minimum necessary documentation through a committeeprocess.
J Research the scope, authority, and current priorities of the Joint Commission onAccreditation of Healthcare Organizations (JCAHO).
J Approach the JCAHO to require documentation of Occupational and EnvironmentalMedicine (OEM) history and pesticide education.
J Approach targeted major managed care organizations to require documentation of OEMhistory and pesticide education.
J Approach family medicine and Ob/Gyn to include Occupational and EnvironmentalMedicine history and pesticide education in their chart-review for certification/recertification.
J Determine whether this is a priority activity area, and address barriers such as institutionalinertia, extra burden on hospitals, clinics, and JCAHO, and time pressure.
Stakeholders
J Federal agencies and foundations that support research and interventions
J Professional associations
J NIOSH Educational Resource Centers
J Health care centers and hospitals
J Community clinics
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Evaluation of Outcomes/Indicators of Success
J Increase in number of grants and level of support available to practicing primarycare providers.
J Increase in publications of research findings and interventions undertaken by providers.
J Report on success stories and lessons learned in the field.
J Adoption of models in other settings.
J Increase in number of continuing education offerings.
J Increase in number of people attending continuing education programs and number ofpeople completing Web-based credits (percentage increase in participation each year).
J Short-term and long term changes in Evaluation and Management coding and workercompensation.
J Questions added to recertification exams of professionals.
J Worker compensation systems in target states are changed to reimburse for work-up ofsuspected pesticide poisoning, and payment is linked to reporting of pesticide exposuresto state registries.
J Quality Assurance/Quality Control mechanisms in targeted health care organizations arechanged to incorporate review of documentation of an occupational and environmentalhistory.
BackgroundOne of the most effective ways to bring about change is to build incentives into existingrequirements and activities of health care plans and practitioners. There are certain key pointsof entry into the health care system that require providers to address specific issues in theirpractices. For example, by integrating pesticide components into worker compensation, E&Mcoding, and quality assurance, the initiative can ensure that pesticide issues will becomeinstitutionalized into health care practice.
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Resources and Tools
R esources of all kinds serve as the “infrastructure” for this initiative. The five resourcecomponents are designed to identify, create, and disseminate the necessary tools tosupport change in both educational and practice settings. Key concerns are to avoid
duplication of existing resources by inventorying the current stock of resources available, andto ensure the scientific credibility and usefulness of resources by establishing a national reviewboard to evaluate them.
Component A: Inventory existing resources — Determine what educational and informationalprograms and materials for health care providers currently exist in education and practicesettings and what gaps should be filled.
Component B: Establish a national review board — Create a national body to determineassessment criteria and evaluate existing resources, with the goal of identifying, selecting,and assessing the ideal resources that primary health care providers use in both educationaland practice settings for prevention, diagnosis, treatment, and referral of pesticide-relatedhealth conditions.
Component C: Create an information gateway — Establish a print, telephone, and Web-based gateway through which primary health care providers can access information andeducational resources.
Component D: Develop teaching/learning resources for educational settings — Identify anddevelop new content resources, tools, and methods for faculty in educational settings.
Component E: Develop new resources for practice settings — Identify and develop newcontent resources, tools, and methods for health care providers in practice settings.
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RESOURCE COMPONENT A:
Inventory Existing Resources
StatementDetermine what educational and informational programs and materials for health careproviders exist in education and practice settings and what gaps should be filled.
Expected OutcomesAn inventory of pesticide resources based upon information from health care providers ineducation and practice settings.
Target AudienceReadiness for Change: This strategy will target health care providers who have alreadydeveloped model tools, resources, and programs so as to create a centralized inventory ofwhat exists and what gaps need to be filled.
Proposed ActivitiesActivity #1Develop and document the inventory methodology to be used in collecting resources,including documentation for the survey instrument and an announcement requestingresources and materials, including placing a solicitation in the Federal Register.
Activity #2Conduct the resources inventory. Key questions to be asked of organizations in the surveyinclude:
J What resources do you use to diagnosis pesticide exposures?
J What resources do you use to treat pesticide exposures?
J What resources do you use to refer pesticide-exposed patients?
J How useful are current resources?
J At what “stage of change” is the resource targeting providers?
J For which target discipline is the resource designed?
J For what practice settings is the resource designed?
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J For what characteristics of patient/community populations are the resources designed?
J What resources are needed that are not readily available?
Stakeholders
J Federal Interagency Planning Committee for this initiative
J Organization conducting the inventory
Evaluation of Outcomes/Indicators of Success
J Inventory completed and available.
J Feedback from Website users indicating additional resources and/or identifying gaps.
J Acknowledgment of a thorough inventory by the national review board.
BackgroundIn order to evaluate the existing resources and to effectively disseminate what is available, aninventory of available resources needs to be created. Such an inventory is already underwayand will be completed as part of this initiative. The inventory will be available online and inprint formats.
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RESOURCE COMPONENT B:
Establish National Review Boardto Evaluate Resources
StatementCreate a national body to determine assessment criteria and evaluate existing resources, withthe goal of identifying, selecting, and assessing the ideal resources that primary health careproviders use in both educational and practice settings for prevention, diagnosis, treatment,and referral of pesticide-related health conditions.
Expected Outcomes
J An established board available for ongoing consultation and review.
J A published document with a list of evaluated and recommended pesticide resources thatprimary health care providers can use in both educational and practice settings forprevention, diagnosis, treatment, and referral of pesticide exposures.
Proposed Activities
J Establish selection criteria for review board membership.
J Establish a multidisciplinary national review board to conduct the evaluation of existingresources.
J Refine the list of suggested evaluation criteria:
O Pilot tested
O Demonstrated level of success
O Regional applicability
O Significant number of participants
O Cost-effectiveness
O Peer review of resources
O Significant relevance
O Related to at least one competency/practice behavior
O Developed by credentialed sources/authors
O Accessibility
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O Credibility of information/sound science
O Convenience
O Endorsement by appropriate professional association
O Approved programs for CE credits
O Built-in incentives to use the resources.
J Convene the national review board to evaluate the existing inventory of resources (ResourceComponent A) using the evaluation process.
J Publish recommended resource document online and as a paper document.
J Assess the usefulness of the resource document to health care providers.
Stakeholders
J Federal Interagency Planning Committee
J National review board members
Evaluation of Outcomes/Indicators of Success
J Published document of resources, online and as a paper document.
J Feedback from health care providers on the usefulness of the resource list (via onlinemechanism and mail-back card inserted in the paper document).
BackgroundThe concept of a national review board came out of the Resources Workgroup’s focus on howpesticide-related resources used in education and practice settings could be evaluated, in theinterests of using the highest quality materials. The review board would be composed of leadersin the areas of pesticides and primary health care.
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RESOURCE COMPONENT C:
Create an Information Gateway
StatementEstablish a print, telephone, and Web-based gateway through which primary health careproviders can access information and educational resources.
Expected OutcomesA fully functional, interactive, informational gateway that provides primary health careproviders with access to readily available and useful pesticide resources.
Target AudienceReadiness to Change, Maintenance: This component targets individuals and organizationswho are looking for models and resources for how to address health effects from pesticidepoisonings, as well as individuals and organizations who have become part of the cadre ofhealth care providers involved in this issue.
Proposed ActivitiesActivity #1Build the gateway using resources gathered through the inventory process and evaluated byreview board.
J Identify existing resource centers that could develop the gateway, under direction of theFederal Interagency Planning Committee.
J Develop or enhance a resource center infrastructure and address logistical issues includinga toll-free number and Website functioning in real time.
J Assign priority access to primary health care providers.
J Link to regional and geographical specific information, coordinated industry Websites,and other resources, universities, associations, etc.
Activity #2Market the gateway and its information/education resources through dissemination channelsto reach primary health care providers in education and practice settings.
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J To build awareness among health care providers: Disseminate persuasive case statements(see Education Component A, Practice Component A for development of case statements)through professional associations, journals, and peers that address the main issues, whyprimary care providers should be concerned, and how to access the gateway.
J To provide tools/resources to health care providers ready to make changes: Disseminate curricularpackages to educational settings and training packages to practice settings. Packages may bedefined as lectures, slides, case studies, exercises, assignments/project ideas, ideas on how toinvolve experts, access to gateway, etc. Packages would be combined from existing resourcesand/or new resources that have undergone peer-review and pilot testing.
J To help health care providers learn of the latest resources: Disseminate concise informationon how to access the gateway, especially the network of expertise. Dissemination methodsinclude posters, flyers at conferences, NPTN clearinghouse, and links on Websites.
J Convene one or more focus groups to evaluate the effectiveness of the dissemination efforts.
Stakeholders
J Federal Interagency Planning Committee
J Organization to manage the gateway
Evaluation of Outcomes/Indicators of Success
J Number of requests for information.
J Number of hits to the Website.
J Number of calls.
J ‘Customer satisfaction’ survey on the Website.
J Feedback from focus groups.
J Degree to which the dissemination efforts are nationwide.
J Degree to which dissemination efforts and resources address primary health care providersat varying ‘stages of change.’
BackgroundA centralized gateway to the wealth of information available and paths to information canbe an efficient way to provide comprehensive access to evaluated, pesticide-related resources.This centralized resource should include emergency information and contacts, educational
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materials, and other resources, and be accessible by an 800 number and via a Website. Thegateway must be able to provide real-time answers to short-term questions as well as largereducational resources. Access must be multi-pronged: phone, Web, print, email/listservs. Itshould contain geographic linkages to local providers, researchers, and sources of localinformation (e.g., local health departments). The gateway will build on existing resourcenetworks, such as NPTN (see box below) and will require a multi-stakeholder partnership foreffective implementation. Clearly, the gateway itself will need extensive marketing in orderto ensure that it is widely used.
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A cooperative effort between Oregon State University and EPA, NPTN providesobjective, science-based, and plain-language pesticide information to the generalpublic, and medical and veterinary communities. It handles over 23,000 calls ayear on topics ranging from toxicology to pesticide poisonings. NPTN’s staff ofpesticide professionals includes toxicologists and a physician trained to:
J help callers interpret and understand health and environmental informationabout pesticides
J answer questions about pesticide labels
J supply general information on the regulation of pesticides in the United States
J access over 300 pesticide resources
J direct callers for pesticide incident investigation, emergency human andanimal treatment, safety practices, clean-up and disposal, laboratory analyses
J confer with private physicians to determine an appropriate treatment planin the event of poisonings
J provide information regarding safety practices for field/farm workers and handlers
J provide callers with information about anti-microbial pesticides (1-800-447-6349) (Monday-Friday).
Toll-free tel: 1-800-858-7378 daily, 6:30 a.m. - 4:30 p.m. (Pacific time); Fax: 541-737-0761; E-mail: [email protected]; Website: http://nptn.orst.edu.
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RESOURCE COMPONENT D:
Develop Teaching/LearningResources for Educational Settings
StatementIdentify and develop new content resources, tools, and methods for faculty to use ineducational settings.
Expected Outcomes
J Teaching modules
J Network of experts and organizations nationwide
Target AudienceReadiness to Change: This component targets faculty in educational settings who are readyto integrate the issue into their curriculum.
Proposed ActivitiesCreate teaching modules for faculty that address pesticides/environmental health and thatrespond to the recommended competencies, the National Guidelines, and the assessment ofeducational institutions.
J Review existing teaching modules collected and evaluated by the national review boardand review the assessment of educational institutions to determine the type of teachingmodules still needed by faculty.
J Identify key experts and/or organizations to develop teaching modules and createcontractual agreements for the development of specific modules.
J Develop pesticide-teaching modules with flexibility for use by different schools,departments, etc.
J Establish a peer review and pilot testing process for the modules developed.
J Distribute teaching modules to all academic health centers and nursing schools.
J Make modules available online (via gateway and/or published resources document).
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Stakeholders
J Faculty who have already developed resources
J Key professional associations for faculty
J Cooperative Extension Pesticide Safety Educators
J State Lead Agency Pesticide Educators
Evaluation of Outcomes/Indicators of Success
J New resources are approved and endorsed by the national review board.
BackgroundGuiding principles for developing new resources include:
J Easy to implement
J Interdisciplinary
J Culturally and geographically relevant
J Measurable outcomes
J Usable in both urban and rural communities.
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RESOURCE COMPONENT E:
Develop New Resources for Practice Settings
StatementIdentify and develop new content resources, tools, and methods for health care providers inpractice settings.
Expected OutcomesIncreased access to and availability of relevant information and resources including expertsin the field, content materials and available data within communities.
Target AudienceReadiness to Change: This component targets practitioners who are ready to integrate theissue into their clinical practice and prevention activities.
Proposed ActivitiesActivity #1Develop a variety of resources, including:
J Training package for a one-day workshop on Pesticides and Health Care Providers:This package could be used to train health care providers in continuing education, coveringthe breadth of topics related to pesticides.
J User-friendly materials:
1. Pocket guides for physicians and nurses, for both print and Web media. Ensure thatguides are dated so that revisions can be made and distributed, and that they containreturn cards for new information and comments.
O Guide I: Highlights of symptoms, treatments, and reference (similar to “Highlights”feature in Recognition and Management of Pesticide Poisoning)
O Guide II: How to take an environmental history (could be adapted fromRecognition manual).
2. “ABCs of environmental health” — a simple tool, similar to the CAGE screening toolfor alcoholism, that will indicate signs and symptoms for screening purposes.
3. Wall posters on pesticides for health care providers to post in their clinical practices
4. Audio cassettes/CDs to listen to in transport to and from a practice setting.
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J Outreach: Use of radio for both patients and primary care providers from Central andLatin American countries.
J Certification of training: Some type of recognition that a primary care provider hascompleted a certain level of training.
J Journal articles in the literature: Encourage researchers to produce professional journalarticles on the subject of pesticide-related health concerns.
J Internet/Web-based materials and training, including video-conferencing, satellite training.
J Encourage creation of a centralized industry Website on pesticide/health data.
Activity #2Increase the participation of professional associations in the support, use, and promotion ofeducational materials and resources.
J Develop model policy statement that can be tailored and adopted by professional associations.
J Coordinate with national organizations to develop policy statements on educating healthcare providers about pesticides (along the lines of those developed by the AmericanAcademy of Pediatrics).
J Encourage development of environmental health committees in professional organizationsand local chapters.
J Coordinate with professional associations to secure more continuing medical education(CME) opportunities at national and regional meetings.
J Build pesticide/environmental health CME into Internet-based offerings by professionalassociations.
Activity #3Establish a national network of experts and organizations that can answer questions andserve as resources to health care providers nationwide.
J Identify existing organizations that have the capability to establish and/or expand a databaseof individuals and organizations.
J Identify areas of expertise to be included.
J Identify experienced professionals and define the parameters of their responsibility.
J Solicit availability for consultation, teaching, guidance, etc.
J Develop a Pesticide Poisoning Orientation Training program to build “practice champions”or motivate providers to become champions. Training could be Web-based, via audio
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cassettes, CDs, or in-person. Short courses (half or full day) could be held in conjunctionwith other professional conferences, and should be integrated with other disciplines.
Stakeholders
J Faculty who have already developed resources
J Key professional associations for faculty
J Cooperative Extension Pesticide Safety Educators
J State Lead Agency Pesticide Educators
J Network of pesticide and pest management experts in land grant colleges and universitiesthroughout the U.S.
Evaluation of Outcomes/Indicators of SuccessJ Increased utilization of community resources.
J Increased number of customized educational programs/materials.
J Increased number of collaborations among resources.
J Number of RFPs related to new and innovative ways to get information to primary care providers.
J Increased number and frequency of pesticide-practice related publications.
J Increased number of CME courses.
J Increased number of presentations in practice settings.
J Numbers of policy statements.
J Numbers of re-certification exams.
J Numbers of questions on exams.
J Increased availability of reimbursement mechanisms.
J Number of people applying for Certificate of Recognition.
J Number of requests made of experienced professionals.
J Number of professionals who agree to participate.
J Diversity of professional background.
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BackgroundA wide range of materials needs to be developed that are credible, convenient, and easy to use.Examples include “cheat sheets,” cassette tapes or CDs that can be listened to in the car, Web-based instruction (depending on how recently the providers graduated and how comfortablethey are with technology). Providers are overburdened and need quick help — either in theform of checklists or a person at the other end of a line.
To the extent that primary care providers keep up with their professional journal literatureand to the extent that there is a sufficient stream of articles in the literature on pesticidediagnosis and treatment, it can be expected that providers will encounter pesticide-relatedinformation in the course of their reading. However, there may well be a gap in articles onpesticide poisoning prevention and diagnosis in the journals that are generally read, a gapthat could be remedied by encouraging researchers to prepare and submit such articles.
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Conclusion
This Implementation Plan is the starting point for a strategic and coordinated effort tochange our national health care system so that it adequately addresses the problemsposed by pesticide poisonings and exposures. The Plan presents the goal of the initiative
and the expected outcomes, and sets forth a strategic direction for how to improve therecognition, management and prevention of pesticide-related health conditions. At the heartof the Plan is a three-pronged strategy for accomplishing the necessary change. The strategyis aimed at improving the teaching of pesticides and environmental health in educationalsettings of nursing, medical, and other health professional schools, changing the way primarycare providers assess and react to pesticide cases in their practice settings, and creating thenecessary new resources for both educational and practice settings that build upon the existingknowledge base and respond to the needs of faculty, students, administrators, and practitioners.The three-pronged strategy and the Plan as a whole are intended to serve as a model for othertoxic exposures and broader efforts to educate health care providers about environmentalhealth problems. It is hoped that this Plan will pave the way for the strategic next steps neededto move forward a common national vision for environmental health awareness, educationand training for health care providers.
Work is already underway on a number of components of the Plan — including developmentof competency guidelines, establishment of a national evaluation panel/review board,conducting an audience assessment through literature review and focus groups, and creationof an information gateway. Most of the remaining components will get underway in the nextthree years. Evaluation of progress will be an ongoing theme during the course of this initiative.The next steps in moving this initiative forward will require the support and participation ofa wide spectrum of stakeholders nationwide. This Implementation Plan can be used as a wayof introducing new additional stakeholders and interested parties to the initiative and ofinvolving them in specific components. The Plan will also form the basis for a National Forumto be convened in 2001.
As work proceeds, workgroup members and other stakeholders are encouraged to stay activein the initiative through e-mail and EPA’s host Website (www.epa.gov/pesticides/safety/healthcare) and to bring the initiative to the attention of colleagues and other contacts in thehealth care world.
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ReferencesAdami, H.O. et al., 1995. “Organochlorine compounds and estrogen-related cancer in women.”Cancer Causes and Control, 6:551-566.
Ahlborg, U.G., L. Lipworth, L. Titus-Ernstoff, et al., 1995. “Organochlorine compounds inrelation to breast cancer, endometrial cancer, and endometriosis: An assessment of thebiological and epidemiological evidence.” Critical Reviews in Toxicology, 25:463-531.
Alavanja, M.C.R, D.P. Sandler, S.B. McMaster, et al., 1996. “The Agricultural Health Study.”Environmental Health Perspectives, 104:362-369.
American Association of Poison Control Centers (AAPCC), 1994. Tabulations prepared forEPA: All Pesticides 1985-1992 Without Concomitant Exposures. Washington, D.C., December.
American Medical Association, 1994. Report 4 of the Council on Scientific Affairs, Educationaland Informational Strategies for Reducing Pesticide Risks (Resolutions 403 and 404), December.
Blondell, J., 1997. “Epidemiology of pesticide poisonings in the U.S., with special reference tooccupational cases.” Occupational Medicine: State of the Art Reviews,Vol. 12.2. April-June.
Centers for Disease Control and Prevention (CDC), 1984. “Organophosphate insecticidepoisoning among siblings — Mississippi.” MMWR. 33:592.
Centers for Disease Control and Prevention, 1999a. “Aldicarb as a cause of food poisoning —Louisiana, 1998.” MMWR. 48:269-271.
Centers for Disease Control and Prevention, 1999b. “Surveillance for pesticide-related illnessduring the Medfly Eradication Program in Florida, 1998.” MMWR. 48:1015-1018, 1027.
Chafee-Bahamon, C., D.L. Caplan, and F.H. Lovejoy, 1983. “Patterns in hospital’s use of aregional Poison Information Center.” American Journal of Public Health, 73:396-400.
Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment,1999. Organophosphates. Department of Health, United Kingdom. Crown Copyright: London.
Davis, D.L., H.L. Bradlow , M. Wolff, et al., 1993. “Medical hypothesis: Xenoestrogens aspreventable causes of breast cancer.” Environmental Health Perspectives, 101:372-377.
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Environews, 1997. “Methyl Parathion Comes Inside.” Environmental Health Perspectives,106(7), July.
Eubanks, M.W., 1997. “Hormones and health.” Environmental Health Perspectives, 105:482- 487.
Harchelroad, F., R.F. Clark, B. Dean, and E.P. Krenzelok, 1990. “Treated vs. reported toxicexposures: Discrepancies between a Poison Control Center and a member hospital.” Veterinaryand Human Toxicology, 32:156-159.
Hoar, S.K., et al., 1986. “Agricultural herbicide use and risk of lymphoma and soft tissuesarcoma.” JAMA, 256:1141-47.
Institute of Medicine, 1988. Role of the Primary Care Physician in Occupational andEnvironmental Medicine, IOM Report, Division of Health Promotion and Disease Prevention,National Academy Press, Washington, D.C.
Keifer, M.C. and R.K. Mahurin, 1997. “Chronic neurologic effects of pesticide overexposure.”Occupational Medicine: State of the Art Reviews, 12(2):291-304.
Levy, B.S., 1985. “The teaching of occupational health in US medical schools: Five-year follow-up of an initial survey.” American Journal of Public Health, 75:79-80.
Litovitz, T.L., M. Smilkstein, L. Felberg, et al., 1997. “1996 Annual Report of the AmericanAssociation of Poison Control Centers Toxic Exposure Surveillance System.” American Journalof Emergency Medicine, 15:447-500.
McCaig, L.F. and C.W. Burt, 1999. “Poisoning-related visits to emergency departments in theUnited States, 1993-1996.” Clinical Toxicology, 37:817-826.
McCaig, L.F., 2000. National Center for Health Statistics. Personal communication to JeromeBlondell, Feb. 7.
National Center for Environment Health (NCEH), 1996. “NCEH Activities during Lorain CountyMethyl Parathion Decontamination Project.” Centers for Disease Control and Prevention.
Peters, H.A., W.A. Croft, E.A. Woolson, et al., 1983. “Arsenic, chromium, and copperpoisoning from burning treated wood” (Letter to the Editor). New England Journal ofMedicine, 308:1360-1361.
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Pope, A.M. and D.P. Rall, eds., 1995. Environmental Medicine: Integrating a Missing Elementinto Medical Education. Committee on Curriculum Development in Environmental Medicine,Institute of Medicine, National Academy Press, Washington, DC.
Pope, A.M., M.A. Snyder, and L.H. Mood, eds., 1995. Nursing, Health, and the Environment.Committee on Enhancing Environmental Health Content in Practice, Institute of Medicine,National Academy Press, Washington, D.C.
Prochaska, J.O., J.C. Norcross, and C.C. DiClemente, 1995. Changing for Good: TheRevolutionary Program That Explains the Six Stages of Change and Teaches You How to FreeYourself from Bad Habits. Avon Books (pb).
Reigart, J.R. and J.R. Roberts, 1999. Recognition and Management of Pesticide Poisonings, fifthedition. EPA#735-R-98-003, Washington, DC.
Robinson, J.C., W.S. Pease, D.S. Albright, and R.A. Morello-Frosch, 1994. Pesticides in theHome and Community: Health Risks and Policy Alternatives. CPS Report, California PolicySeminar, Berkeley, CA.
Rosenstock, L., M. Keifer, W.E. Daniell, et al., 1991. “Chronic central nervous system effects ofacute organophosphate pesticide intoxication.” Lancet, 338:223-227.
Savage, E.P., T.J. Keefe, L.M. Mounce, et al., 1988. “Chronic neurological sequelae of acuteorganophosphate pesticide poisoning.” Archives of Environmental Health, 43:38-45.
Schenk, M., S.M. Popp, A.V. Neale, and R.Y. Demers, 1996. “Environmental medicine contentin medical school curricula.” Academic Medicine, Vol. 71, No. 5, May.
Schnitzer, P.G. and J. Shannon, 1999. “Development of a surveillance program for occupationalpesticide poisoning: Lessons learned and future directions.” Public Health Report, May-Jun;114(3):242-8.
Sever, L.E., T.E. Arbuckle, and A. Sweeney, 1997. “Reproductive and developmental effects ofoccupational pesticide exposure: The epidemiologic evidence.” Occupational Medicine: Stateof the Art Reviews, 12(2):305-325.
Slovic, P., B. Fischhoff, and S. Lichtenstein, 1980. "Facts and fears: Understanding perceivedrisk." In: Schwing, R.C. and W.A. Albers, Jr. eds., Societal Risk Assessment: How Safe is SafeEnough? New York, Plenum Press.
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Steenland, K., B. Jenkins, R.G. Ames, et al., 1994. “Chronic neurological sequelae toorganophosphate pesticide poisoning.” American Journal of Public Health, 84:731-36.
Stephens, R., A. Spurgeon, I.A. Calvert, et al., 1995. “Neuropsychological effects of long-termexposure to organophosphates in sheep dip.” Lancet, 345:1135-1139.
U.S. EPA, 1998a. Office of Pesticide Programs Annual Report for FY 1997. Office of Prevention,Pesticides, and Toxic Substances, EPA #735-R-97-003, January.
U.S. EPA, 1998b. Pesticides and National Strategies for Health Care Providers; WorkshopProceedings. Office of Prevention, Pesticides, and Toxic Substances, EPA #735-R-98-001, July.
U.S. EPA, 1999. Pesticides Industry Sales and Usage: 1996 and 1997 Market Estimates. Office ofPrevention, Pesticides, and Toxic Substances, EPA #733-R-99-001, Washington, D.C.
U.S. General Accounting Office, 1993. Pesticides on Farms: Limited capability exists to monitoroccupational illnesses and injuries. (GAO/PEMB-94-6) Washington, D.C., December.
Veltri, J.C., N.E. McElwee, and M.C. Schumacher, 1987. “Interpretation and uses of datacollected in Poison Control Centers in the United States.” Medical Toxicology, 2:389-397.
Whitmore, R.W., J.E. Kelly, and P.L. Reading, 1992. National Home and Garden PesticideSurvey: Final Report, Volume 1, 1992. Research Triangle Institute NC: RTI\5100.121F,Research Triangle Park, NC.
Whorton et al., 1979. “Testicular function in DBCP exposed workers.” Journal of OccupationalMedicine, 21:161-166.
Wigle, D.T., R.M. Semenciw, K. Wilkins, et al., 1990. “Mortality study of Canadian male farmoperators: Non-Hodgkin’s lymphoma mortality and agricultural practices in Saskatchewan.”Journal of National Cancer Institute, 82:575-82.
Zahm, S.H., D.D. Weisenburger, P. Babbitt, et al, 1990. “A case-control study of non-Hodgkin’slymphoma and the herbicide 2,4-dichlorophenoxyacetic acid (2,4-D) in eastern Nebraska.”Epidemiology, 1:349-356.
Zahm, S.H., M.H. Ward, and A. Blair, 1997. “Pesticides and Cancer.” Occupational Medicine:State of the Art Reviews, 12(2):269-289.
Zweiner, R.J. and C.M. Ginsburg, 1988. “Organophosphate and carbamate poisoning in infantsand children.” Pediatrics, 81:121-6.
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Glossary
AAP American Academy of Pediatrics
AACN American Association of Colleges of Nursing
AAFP American Academy of Family Physicians
AAMC Association of American Medical Colleges
ACNM American College of Nurse Midwives
AAOHN American Association of Occupational Health Nurses
ACOEM American College of Occupational and Environmental Medicine
AMA American Medical Assocation
ANA American Nurses Association
APN Advanced Practice Nurse
ATSDR Agency for Toxic Substances and Disease Registry
CDC Centers for Disease Control and Prevention
CE Continuing education
CME Continuing medical education
CNS Clinical nurse specialist
E&M Evaluation and Management
EPA Environmental Protection Agency
FNP Family Nurse Practitioner
GNP General Nurse Practitioner
HHS Department of Health and Human Services
HRSA Health Resources and Services Administration
NEETF The National Environmental Education & Training Foundation
NIEHS National Institute for Environmental Health Sciences
NIH National Institutes of Health
NIOSH National Institute for Occupational Safety and Health
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NLN National League of Nursing
NPTN National Pesticides Telecommunications Network
OSHA Occupational Safety and Health Administration
PNP Pediatric Nurse Practitioner
RFA Request for Applications
RFP Request for Proposals
USDA U.S. Department of Agriculture
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Appendix A:Expert Panel Proceedings
To launch the Pesticides and National Strategies for Health Care Providers initiative, EPAand several other federal agencies convened an expert forum to begin the process ofdeveloping national strategies that will improve the education and awareness of health
care providers in dealing with pesticide-related health concerns. The workshop, held on April 23-24, 1998 in Arlington, VA, was sponsored by EPA in collaboration with the Department of Healthand Human Services, Department of Agriculture, and Department of Labor. The Association ofTeachers of Preventive Medicine and The National Environmental Education and TrainingFoundation worked with these federal agencies to organize the event. (See U.S. EPA, 1998b.)
The expert forum was conceived of as a deliberative session of representatives of 16 healthorganizations, open to the public, and with comments and questions from federal agenciesand outside observers. The panel included representatives from: American Academy of FamilyPhysicians, American Academy of Pediatrics, American Academy of Physician Assistants,American Association of Colleges of Nursing, American Association of Poison Control Centers,American College of Emergency Physicians, American College of Occupational andEnvironmental Medicine, American Nurses Association, Council of State and TerritorialEpidemiologists, Migrant Clinicians Network, National Center for Farmworker Health,National Organization of Nurse Practitioner Faculties, National Pesticide TelecommunicationsNetwork, National Rural Health Association, Pennsylvania State University/NationalAgromedicine Consortium, and Suncoast Community Health Centers.
Concerns About Provider Education and TrainingThe panel agreed that the primary focus of this initiative should be on primary care providers.The panel found that primary care providers are not sufficiently trained at any stage oftheir education about pesticide exposure. The panel also recognized that the lack of trainingis larger than just pesticides and reflects a serious deficiency in education on environmentaland occupational health. The panel briefly summarized the main concerns in providerknowledge about pesticide exposures:
J Pesticide exposures are often underreported.
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J Providers often do not know how and where to report pesticide exposures; sometimes thereporting is considered burdensome given their demanding work environments.
J Health conditions associated with pesticide exposures are often misdiagnosed.
J Providers do not often see acute pesticide poisoning, and they do not possess enoughknowledge to recognize chronic cases.
J Providers have not received training on pesticide exposures during their years of formal education.
J Pesticide exposures and associated health conditions are difficult topics to teach becausethey require additional knowledge on toxicology and other topics which are often notincluded in the curriculum of health professional education.
Expected Outcomes for Primary Care ProvidersThe panel discussed at length what should be expected of primary care providers. Agreementwas reached that all primary care providers should:
J Be knowledgeable about pesticides and recognize pesticide exposures as a health concern.
J Be able to diagnose and treat pesticide exposures at the earliest possible time and completethe appropriate follow-up and referral (exposure management).
J Take preventive measures in both the clinical and community settings, includinganticipatory guidance and community education (prevention management).
J Report exposures and health outcomes of either patients or communities.
J Access the appropriate resources/specialists (local, regional, and national).
Expert Panel’s Overarching StrategiesThe expert panel generated specific strategies that were consolidated into four general topic areas:
1. Define and recommend basic environmental health (emphasizing pesticides) competenciesfor primary care providers.
2. Develop a set of education and training strategies for students and primary care providerson the subject of pesticide-related health concerns.
3. Raise the awareness of primary care providers on pesticide issues and risk factors throughprofessional meetings, informational mailings by professional associations, and journal articles.
4. Centralize information resources for primary care providers and strengthen their linkageto existing resources.
The panel recommended that three workgroups be created to develop strategies on education,practices, and resources.
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Expert Panel Membership
Joni Berardino, MS, LSWNational Center for Farmworker Health
Candace M. Burns, PhD, ARNPNational Organization of Nurse Practitioner Faculties, andUniversity of South Florida College of Nursing
Joe Fedoruk, MD, DABT, CIHAmerican College of Occupational and Environmental Medicine
J. Ward Donovan, Jr., MD, FACEPAmerican College of Emergency Physicians, andPennsylvania University Poison Center, Milton S. Hershey Medical Center
Rugh Henderson, MD, MPHNorth American Agromedicine Consortium,Pennsylvania Agromedicine Program, and Penn State University College of Medicine
Michael Hodgman, MDNational Rural Health Association, andBassett Healthcare/NY Center for Agricultural Medicine and Health
Andrea R. Lindell, DNSc, RNAmerican Association of Colleges of Nursing, andUniversity of Cincinnati College of Nursing
Mary Miller, MN, ARNPAmerican Nurses Association, andWashington State Department of Labor and Industries
Karen Mountain, MBA, MSN, RNMigrant Clinicians Network
Dennis Penzell, DO, FACPSuncoast Community Health Centers, Inc.
George C. Rodgers, Jr., MD, PhDAmerican Association of Poison Control Centers, andUniversity of Louisville School of Medicine
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Jackilen Shannon, PhDCouncil of State and Territorial Epidemiologists, andTexas Department of Health
Elisabeth Spector, MD, MPHAmerican Academy of Family Physicians
Roger F. Suchyta, MDAmerican Academy of Pediatrics
Greg P. Thomas, PA-CAmerican Academy of Physician Assistants
Sheldon Wagner, MDNational Pesticide Telecommunications Network, andOregon State University
Speakers and FacilitatorWilson AugustaveFinger Lakes Migrant Health Care Project
Louise M. Rauckhorst, EdD, MSNPhilip Y. Hahn School of Nursing, University of San Diego
Mark G. Robson, PhD, MPHEnvironmental and Occupational Health Sciences Institute, andRutgers University
Susan T. West, MPH, FacilitatorThe National Environmental Education and Training Foundation, Inc.
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Appendix B: SummaryProceedings from Workgroups
This appendix provides a brief summary of the deliberations of the three workgroupscreated under this initiative and a list of their members. The strategies and plans thatemerged from the workgroup meetings are the subject of this Implementation Plan.
The workgroups discussed competencies and expected outcomes, and devoted some time tobrainstorming sessions on overall strategies and plans of action. Members held small groupdiscussions for the better part of the second day of each meeting, to flesh out the strategiesand action items. The groups then reviewed the strategies and decided on next steps. Bothshort-term (1-3 year timeframe) and longer-term actions (3-5 years) were identified. Themeetings were facilitated by Susan West of The National Environmental Education and TrainingFoundation (NEETF).
The Education Workgroup was charged with developing a national strategic plan to enableundergraduate and graduate formal education and training institutions to prepare primarycare providers to prevent, diagnose, treat, and refer patients exposed to pesticides. Theworkgroup was expected to set (and/or select already established) competencies for theeducational setting, and to identify strategies on how to achieve those competencies througheducation, training, and raising student awareness.
The Practice Workgroup was charged with developing a national strategic plan for improvingthe practice of primary care providers in preventing, diagnosing, treating, and referring patientsexposed to pesticides. This group, too, was expected to set (and/or select already established)competencies for the practice setting and to identify strategies on how to achieve thosecompetencies through education, training, and raising awareness.
The Resources Workgroup was charged with developing a national strategic plan whichaddresses an effective method of linking, centralizing, and/or disseminating an array ofresources for the prevention, diagnosis, treatment, and referral of patients exposed to pesticides.This plan would also evaluate existing assessments of resources, identify gaps, and begin todevelop needed resources for health care providers.
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Key PrinciplesKey principles and findings emerging from the three 1999 workgroups include:
J Pesticides must be seen in the context of environmental and occupational health.All three workgroups expressed the opinion that pesticides are a useful and importantfocus of attention in themselves; however, pesticides must also be seen as a stepping-stone for the underrecognized and broader issue of environmental and occupationalhealth as a whole.
J Gaining attention and raising awareness are the primary challenges. One of the mostdifficult obstacles is simply gaining the attention of students, faculty, and primary careproviders to the issue of pesticides and/or environmental health. Curricula are crowded,providers are busy, and time is at a premium. Nevertheless, sometimes a single caseencounter can have long-lasting effects. Much of the effort of the workgroups was drivenby the need to gain attention and raise awareness. Strategies include developing casestatements, creating monetary and professional incentives, nurturing pesticide/environmental health “champions” and model practices and convening focus groups tobetter understand providers’ communication styles.
J Environmental histories are gateways. Few primary care providers ask patients thequestions that would be likely to alert them to the possibility of a pesticide-relatedillness. Although it is important for primary care providers to take environmentalhistories, both workgroups recognized that a full environmental history can sometimestake up the entire patient visit. However, getting primary care providers to ask just afew simple questions — such as ‘Where do you work?’ and ‘Do you think your problemsare related to something that happened at work or at home?’ — could go a long waytoward uncovering pesticide-related health conditions and raising awareness about theenvironment in which patients live.
J There is a spectrum of pesticide-related health conditions. Stereotypes of pesticideillness — insecticides, farmworkers, acute poisoning, cholinesterase testing — may coveran important segment of the population, but they by no means cover the entire field.Students, faculty, and primary care providers must come to understand the widespectrum of pesticide-related health concerns: low-dose chronic effects as well as acute,high-dose poisonings; effects on children, people with chemical sensitivities, othervulnerable populations; the wide variety of pesticide products on the market; urban,rural, and suburban settings.
J The need is for credible, convenient, and easy-to-use resources. The best way to reachalready overburdened primary care providers is by ensuring that the resources availableto them on pesticide-related illnesses are scientifically credible, easy to access, and providequick answers to providers’ questions.
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J The importance of understanding the audience cannot be overstated. Primary careproviders work in a wide variety of settings and have varying levels of exposure to pesticide-related health issues. Understanding primary care providers — their backgrounds, level ofawareness and knowledge about pesticide issues, and preferred modes of receivinginformation — is essential to effectively targeting and reaching the audience for this initiative.
J Evaluation plays a key role. There is a strong need for expert evaluation of the resourcescurrently available to primary care providers on pesticide topics and for ensuring thatnew materials developed through this initiative meet stringent evaluation criteria.
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I have been challenged by some
of the most supportive faculty
who say, “You haven’t made a
strong enough case.” We
haven’t effectively made the
case to incorporate
environmental health in
general... Until we do that, we’ll
always be an afterthought.— Madaleine Ochinang, MS
Education Workgroup
One of the key issues that workgroup members grappled with over the course of themeeting is the need to gain the attention of health care students, faculty, and primarycare providers despite the fact that their time and attention are in high demand
elsewhere. Many members noted that there is little time in the basic undergraduate curriculumfor pesticide and environmental health material. It would be unreasonable to expect morethan a total of 30-40 hours over the course of a four-year degree program; a more modest riseto just 10 hours of instruction would stand a better chance of acceptance. The key is to get theeducation setting both interested in and comfortable with pesticide issues.
Making the CaseWorkgroup members agreed on the need to “make the case” to medical and nursing schools
about the importance of environmental health education andthe breadth of the problem of pesticide-related health concerns.Even the most supportive faculty challenge why environmentalhealth is important to teach.
Workgroup members spent considerable time discussing how tospark the interest of faculty and students. One workgroup membernoted that environmental poisonings are seldom encountered bymedical school students. The best way he has found to motivatemedical students is to have them accompany primary care physiciansin rural area practices so that they can experience the scope ofoccupational medicine first-hand. The payoff is that students valuethis practical type of learning enormously, and that it has a greaterimpact than hearing lecture after lecture on the same topic. It alsocombats one of the problems of the practice setting, which is that
primary care providers often do not perceive the agricultural environment as a workplace.
“Make it Easy for Them to Let Us In...”How will educational institutions allow material on pesticides/environmental health into theircurriculum, and how can the materials be designed to “make it easy for them to let us in?” Itis important to identify where in the curriculum the materials should be inserted. Usually theschools have a flow of courses/topics and the group could suggest where a given topic inenvironmental health would fit. The aim of this initiative is not to overwhelm medical andnursing students with a vast amount of information. Developing some tools along the lines ofthe successful “10 Steps to Identify Cancer” would be a useful approach.
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“Teachers Don’t Teach What They Don’t Know...”It was noted that “Teachers don’t teach what they don’t know... If you make it relevant to them,they’ll find a way to teach their students.” Several workgroup members raised the issue that manyfaculty are not comfortable teaching the full range of subjects involved in pesticides. For example,pharmacology professors may lack the clinical expertise to teach about pesticides; other medicalfaculty may lack the toxicology background. Others agreed that it might be difficult to find enoughfaculty with competence in pesticides/environmental health (environmental health). Workgroupmembers discussed at some length whether faculty should be trained to become comfortablewith, or expert at, teaching pesticides/environmental health subjects, or whether it is sufficient forfaculty to know of experts in their local area whom they can tap as needed.
Merely making materials available is not sufficient — it is not true that “if you build it, they willuse it.” The situations where new material has worked best in medical schools is where there wasan advocate or champion who pushed until the material was included in the curriculum. Astudy at the Worcester School of Nursing reported that the number one barrier to integratingenvironmental health into nursing curricula — which the deans of nursing schools supported— was the absence of faculty with the knowledge and confidence to carry out that integration.
Several models were discussed, including the 26 NIEHS five-year grants for mid-career fundingof environmental health positions, which provided half of the faculty’s salary plus evaluationcomponents, and the 1990-95 faculty development grant program at the University of SouthFlorida that supported curriculum development and research in substance abuse. Facultyspent the first two of the five years in becoming experts in their chosen areas — throughseminars, courses, networking with other experts, etc.
Workgroup members discussed the “fragile toehold” that environmental health coursescurrently have in health care education. There is no additional funding for teaching pesticides/environmental health courses and environmental health is not a “revenue-generator.” Thismay have particularly problematic implications for undergraduate education. Increasingly,faculty members need to generate funding to support their own salaries. “Contextual realities”are important. Of the 126 environmental health science centers around the country, possibly20 are on the verge of disappearing. The workgroup discussed the possibility of developingfellowships around pesticides in specialties that are highly valued within medical schools,since pesticides affect multiple systems in the body. This would require the time of in-housefaculty to incorporate existing resources and information into an institution’s curriculum.
Convincing the Examination BoardsOne way to motivate change in curriculum, workgroup members agreed, is to convince themedical and nursing examination boards of the importance of environmental health in thecoming years, and push them to incorporate environmental health questions on their exams.
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This would also be one of the better ways to institutionalize the subject matter over the longterm. Workgroup members felt that some of the boards would be receptive to a concertedeffort in this area. For example, the Residency Review Committee for Pediatrics in 1996 adoptedtwo recommendations on children’s environmental health.
The workgroup discussed whether public education and K-12 education should also be dealtwith as part of this initiative. The group noted efforts on environmental education becomingincorporated into K-12 education, partly through the support of EPA and the National Instituteof Environmental Health and Sciences. But while many K-12 schools are teaching ecologicaleffects, there is relatively little being taught about the human health effects of the environment.This is a ripe opportunity, and one which would have advantages down the line, with studentsentering medical school already having an awareness of pesticides/environmental health issues.Despite the importance of raising awareness and education in the larger educational sphere,however, the workgroup decided that it fell outside the scope of this initiative, which focuseson educating primary␣ care providers. The group recommended that the issue be addressed inother ongoing initiatives.
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Education Workgroup MembershipCo-ChairsAndrea Lindell, DNSc, RNAmerican Association of Colleges of Nursing, andUniversity of Cincinnati, College of Nursing
Ameesha Mehta, MPHOffice of Pesticide ProgramsU.S. Environmental Protection Agency
FacilitatorSusan West, MPHThe National Environmental Education and Training Foundation, Inc.
MembersAmy Brown, PhDAmerican Association of Pesticide Safety Educators, andUniversity of Maryland-College Park
Candace Burns, PhD, ARNPNational Organization of Nurse Practitioner Faculties, andUniversity of South Florida
Joan Spyker Cranmer, PhDUniversity of Arkansas Medical School
Miriam CruzEquity Research
Kesner Flores, EMTCortina Indian Rancheria, Wintum Environmental Protection Agency
José GarciaEquity Research
Rugh Henderson, MD, MPHNorth American Agromedicine Consortium,Pennsylvania Agromedicine Program, and Penn State University College of Medicine
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Matthew Keifer, MD, MPHNIOSH Agricultural Health and Safety Centers, andUniversity of Washington
John McCarthy, PhDAmerican Crop Protection Association
Claudia Miller, MDUniversity of Texas Health Science Center-San Antonio
Madaleine Ochinang, MSFormerly with the Consortium for Environmental Education in Medicine
Marcia Allen Owens, JDMinority Health Professions Foundation
Annette Perez, RNC, MSN, CNM, PhDAmerican College of Nurse Midwives, andUniversity of Texas-El Paso, College of Health Sciences
J. Routt Reigart, MDMedical University of South Carolina, Department of Pediatrics
Elaine R. Rubin, PhDAssociation of Academic Health Centers
Barbara Sattler, RN, DrPHUniversity of Maryland, School of Nursing
Leonel Vela, MDMigrant Health Advisory Council, andTexas Tech Health Sciences Center
Federal Agency Representatives
Elizabeth Blackburn, RNOffice of Children’s Health Protection, U.S. EPA
Jerome Blondell, MPH, PhDOffice of Pesticide Programs, U.S. EPA
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Barbara Brookmyer, MD, MPHBureau of Health Professions, Division of MedicineHealth Resources and Services Administration
Ruth Kahn, DNScBureau of Health Professions, Division of MedicineHealth Resources and Services Administration
Dalton Paxman, PhDOffice of Disease Prevention and Health Promotion,U.S. Department of Health and Human Services
Rosemary Sokas, MD, MOHNational Institute of Occupational Safety and Health
Delta Valente, MPAOffice Pesticide Programs, U.S. EPA
Joan Weiss, PhD, RN, CRNPBureau of Health Professions, Division of NursingHealth Resources and Services Administration
Peter Wood, MSAgricultural Marketing Service, U.S. Department of Agriculture
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How do you know that what
you’re seeing is not the flu, it’s
really organophosphate
exposure? If you think it’s the
flu and you never ask any of
the questions, this guy is going
to walk out of your office and
you’re still going to think it’s
the flu.— Shelley Davis
Farmworker Justice Fund, Inc.
Practice Workgroup
L ike the Education Workgroup, the Practice Workgroup spent a great deal of timediscussing how to motivate change. Recognizing that primary care providers are busyand confront a myriad of public health issues and illnesses, what is the best way to gain
their attention to ensure that they ask the right questions?
One answer is that what providers see in their practice is what they remember. If primary careproviders do not see enough acute cases of pesticide-related illness, they will not consider itimportant enough to pay attention. However, this is a classic Catch-22 situation, because ifproviders aren’t aware of pesticide poisoning, they won’t recognize the cases. The lack of datain this area makes it hard to convince primary care providers that they need to alter theirpractices. One way for primary care providers to be sensitized to the possibility of pesticidepoisoning is to become knowledgeable about the local community.
What Should Primary Care Providers Know?Workgroup members noted that we need to keep our demands on physicians limited;
primary care providers shouldn’t be expected to betoxicologists. Instead, it is often patients who are directingphysicians to focus more on pesticides and environmentalhealth by the questions they bring up. Some workgroupmembers felt that it would be enough to have primary careproviders be aware of the possibility of pesticide-related healthconditions, know what questions to ask, and know where togo to get additional help. Others argued that minimumcompetencies, or practice changes, are needed. For example, aprimary care provider shouldn’t let a patient walk out of theoffice without ascertaining the possibility of exposure. Theprovider shouldn’t just ask when a patient last vomited, butask if the vomiting coincided temporally with something thathappened at work. Knowing when to do a cholinesterase testingis extremely important for all primary care providers. Suchtesting, for example, is essential to establish that a person has
been harmed for purposes of workers’ compensation, so that medical bills are reimbursed.
Two workgroup members pointed out that getting health care providers to ask a few simplequestions would go a long way toward raising awareness of patients’ environmental healthissues, without requiring these providers to do additional legwork in the community. Two
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simple questions might be: (1) Where do you work? and (2) Do you think your problems arerelated to something that happened at work?
The workgroup devoted an extensive amount of time to the discussion of competencies forprimary care providers. (See Practice Component B on page 66 for more details.) Manyworkgroup members thought that although “competencies” was an appropriate term for aneducational setting, in a practice setting the term implied that primary care providers areincompetent if they don’t remember all of the material. They preferred to use terms such as“knowledge and skill outcomes,” “expected practice skills,” or “content.”
A Two-Track System?One important aspect of the question of “what providers should know” is whether primarycare providers in certain communities should know more than providers in other areas. Forexample, should there be different levels of knowledge and skills for primary care providers inagricultural areas compared to providers in urban or suburban settings?
While the issue was not resolved, the consensus appeared to be that all primary careproviders should have a certain minimum content level of knowledge and skill related topesticides/environmental health. On the other hand, it may be that primary care providersin agricultural communities have an added function, going beyond the minimum inrecognition, diagnosis, and management pesticide-related illness to a larger role inprevention and education, and advising their patients about such things as heat stress,prenatal care, pesticides, etc.
Making Change HappenHow does change actually happen? Workgroup members discussed the difficulties in bringingabout changes in health care. The literature on continuing education shows the need for amultifaceted approach. Continuing education alone has little impact without additional visitsto clinics, feedback loops, hands-on workshops, etc. Even on grand rounds, occupational andenvironmental medicine subjects get very poor turnout.
Other IssuesWorkgroup members stressed the need for research in a number of areas, including researchon human exposure, biomonitoring, and the extent to which pesticide poisonings are currentlybeing misdiagnosed in primary care practices.
It is important to look at interconnections between the clinical setting, community setting,reporting, and the regulatory context, even though primary care providers may not see theseinterconnections. For example, it is not clear that primary care providers realize the importance
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of their role in reporting cases of pesticide illness both for regulating harmful pesticides andfor efforts to make safer pesticides. Upon investigation, some incidents may turn out to havebeen a violation of the label restrictions; but in some cases, pesticide poisoning occurs withno apparent label violation. That information is extremely important, even if it cannot beproven conclusively.
Another connection that does not generally work well is with worker compensation systems.Even in Washington State, which is often pointed to as the model for an integrated reporting/surveillance/worker compensation system (see box on page 82), the system is based on “objectivefindings.” Most pesticide illnesses yield signs and symptoms rather than objective findings, sopatient claims may be denied. Primary care providers need help understanding what the medicalrules of evidence are so that patient claims won’t be rejected. One model might be Colorado’ssystem of associating occupational categories with subjective symptoms (e.g., carpal tunnel);something similar could be done for pesticides. Physicians also need to know how to write uptheir findings, about statutes of limitations for repeat injuries, and where to go for help. Finally,states need to reimburse for relevant diagnostic testing for pesticide illness. At present, onlyWashington State reimburses for diagnostic evaluations.
Defining worker compensation requirements related to pesticide illnesses would attract theattention of medical associations and their members; physicians would know that they couldget paid for this category of health concern. In the California worker compensation system,physicians don’t get paid if they don’t report; such an incentive would likely encourage reportingif it were used more widely. Despite the anticipated difficulties of affecting workercompensation systems, workgroup members agreed on the importance of tackling them. Halfa dozen states are the sole insurers on worker compensation and in those states, the statecommission would be the only organization to deal with. It was also pointed out that sixstates — California, Texas, Florida, Oregon, Washington, and North Carolina — probablycover 70 percent of agricultural workers, and might be the natural focus of attention for thistype of effort.
Workgroup members agreed that community health workers are an important part of the healthcare team. Caseworkers and community health workers are needed to go out and work withvulnerable populations. They can be particularly important in conducting follow up with migrantworkers and bringing them back into the health care system. The workgroup raised, but did notreach a consensus on, whether to widen the scope of the initiative to involve the family, the roleof the physician in the workplace, or the role of health professionals in the community.
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Practice Workgroup MembershipCo-ChairsBonnie Rogers, RN, DrPH, COHN-S, FAANAmerican Association of Occupational Health Nurses andUniversity of North Carolina-Chapel Hill, School of Public Health
Karen Pane, RN, MPA, CMCNHealth Resources and Services AdministrationU.S. Department of Health and Human Services
FacilitatorSusan West, MPHThe National Environmental Education and Training Foundation, Inc.
MembersSheila Brown Arbury, RN, MPHAssociation of Occupational and Environmental Clinics
Shelley DavisFarmworker Justice Fund, Inc.
J. Ward Donovan, MD, FACEPAmerican College of Emergency Physicians,Pennsylvania University Poison Center, and Milton S. Hershey Medical Center
Harold Harlan, PhDNational Pest Control Association
Barbara Hatcher, PhD, MPH, RNAmerican Public Health Association
Ann Linden, CNM, MSN, MPHAmerican College of Nurse Midwives
Mark Miller, MDAmerican Academy of Pediatrics
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Mary Miller, MN, ARNPAmerican Nurses Association, andWashington State Department of Labor and Industries
Karen Mountain, MBA, MSN, RNMigrant Clinicians Network
Diane MullAssociation of Farmworker Opportunity Programs
Patrick O’Connor-Marer, PhDAmerican Association of Pesticide Safety Educators,University of California Statewide IPM Project, andUniversity of California Agricultural Health and Safety Center
John Pickle, RS, MSEHWeld County Health Department - Greeley, CO
George C. Rodgers, Jr., MD, PhDAmerican Association of Poison Control Centers, andUniversity of Louisville School of Medicine
Rachel Rosales, MSHPTexas Department of Health
Cathy Simpson, MDWayne State University, School of Medicine
Gina Solomon, MD, MPHNatural Resources Defense Council
Sheldon Wagner, MDNational Pesticide Medical Monitoring Program, andOregon State University
John Wheat, MD, MPHNorth American Agromedicine Consortium, andUniversity of Alabama at Birmingham, School of Medicine
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Federal Agency RepresentativesBarbara Brookmyer, MD, MPHBureau of Health Professions, Division of MedicineHealth Resources and Services Administration
Frank DavidoOffice of Pesticide Programs, U.S. EPA
Eva Montoya, MSN, RNBureau of Primary Health Care, Migrant Health Program,Health Resources and Services Administration
Ana Maria Osorio, MD, MPHOffice of Pesticide Programs, U.S. EPA
Ana Marie PuenteBureau of Primary Health Care, Border Health,Health Resources and Services Administration
Capt. Barry Stern, MPHBureau of Health Professions, Health Resources and Services Administration
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When I train residents I tell them:
you’ll do a lot better if you don’t
assume you’re the primary
provider. The primary provider is
often the grandmother or an elder...
The natural system of health care in
the community is alive and well.
We need to recognize the system,
not try to change it, and partner
with it to be effective.— Angelina Borbon, RN
Alameda County Lead PoisoningPrevention Program
Resources Workgroup
B uilding on the ideas of the Education and Practice Workgroups, the ResourcesWorkgroup began its discussion by examining the types of resources that are used ineducational and practice settings. The workgroup then undertook a more detailed
exploration of key issues relating to resources, including: the credibility of sources ofinformation, defining and understanding the audience, reaching the target audience withappropriate resources, and evaluating the effectiveness of resources.
Credible Sources of InformationThe Resources Workgroup felt strongly that resources created or promoted through this
initiative must be credible and scientifically sound. Credibilitymust form the basis for the initiative’s efforts. The groupexplored the sources of information that health care providersand the public currently use, and the credibility of differentinformation sources in different communities. Oneworkgroup member suggested that the public trusts theuniversities first, the federal government next, state wateragencies after that, and state agriculture departments afterthat. In many places, the community health worker plays akey role. There are 78 different names for community healthworkers in the U.S., and that although they are generallyconsidered “non-professional,” they are the most trustedhealth care workers and have the highest ability to changebehavior. Standards for community health workers are onlystarting to be developed as community colleges get involvedin their training. Unfortunately, environmental health is notgenerally taught as part of their training.
A related issue that the group considered is sensitivity to local concerns and parlance.
Reaching the Target AudienceThe workgroup’s discussions emphasized the importance of defining and understanding thetarget audience of primary care providers. Aware that the universe of health care providersruns into the millions, the group explored ways of segmenting the universe — by type ofprovider, population served, and practice setting, or by matching types of providers toepidemiologic cases of pesticide use or abuse.
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The workgroup devoted considerable time to a discussion of the varying levels of needs ofprimary health care providers. One workgroup member stated that “it is not clear that wereally know what health care providers want and need” in the way of educational andinformation resources. It will be important to examine the extensive literature on how healthprofessionals learn in order to determine the most effective approaches.
The workgroup explored in detail the Stages of Change model created by Prochaska andDiClemente (Prochaska, 1995). The model looks as behavior change as a process rather thanan event, and describes how individuals are at varying levels of motivation, or readiness tochange. The model outlines a continuum of behavior change that can be used to helpunderstand where the target audience is on the continuum, and to effectively reach the audience(through targeted messages, strategies, and programs) to ensure behavior change. (See Table3 on page 20 and discussion of how the model can be adapted to the current initiative.)
Workgroup members examined existing resources in an effort to determine “what works”and identify gaps. Members reviewed the guide, “Preliminary Resources Materials,” developedby The National Environmental Education and Training Foundation and mentioned additionalmaterials. Workgroup members discussed all aspects of providing effective resources — typesof resource materials, settings in which they are delivered, delivery mechanisms, modes ofdissemination, and motivation for use.
Professional associations could play a big role in reaching member providers. The groupdiscussed the types of technology that providers are most comfortable with, and acknowledgedthat while health care providers lag behind in their use of the Internet, they will no doubtincrease their usage over time. Nevertheless, the Web can be a “giant disorganized mess of baddata, good data, and it takes time to learn how to use it.” Providers will continue to needquick and easy ways of accessing the information they seek. Some members argued thatcontinuing medical education has been shown not to be an effective way to change behaviorand that consensus statements of professional associations can take a long time to developand to have an impact. It is important, however, to approach the target audiences and find outwhere they obtain information.
Evaluating ResultsSome type of measurement and evaluation effort is certainly needed for this initiative. Evaluationand measurement are relevant for several purposes — for assessing the “baseline,” i.e., the currentstate of awareness and involvement of primary care providers, for evaluating the quality ofexisting resources, for helping to design effective new resources and dissemination strategies,and for determining the success of the initiative.
Workgroup members noted that a great deal of attention has been given to measuring the degreeto which educating health care providers on nutrition, tobacco, and other issues has led to
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measurable changes in practice as well as changes in patient practices. Even with tobacco, “thewhole world is trying to get physicians to counsel their patients who smoke to stop smoking.”Nevertheless, only 30-60 percent of physicians appear to do so, and measuring this activity hasbeen very difficult. The group agreed that qualitative research, including holding focus groups,would be an appropriate tool for this initiative. It was suggested to begin with a summary of theliterature in this area. Several provider associations (clinics, pediatricians, family physicians,etc.) represented on this workgroup could provide a source for focus group participants.
Other IssuesThe role of the public in spurring health care providers’ interest was duly noted. Increasingly,patients are a big source driving the physicians’ interest in pesticides: “Patients instigate byasking a question that the physician or nurse can’t answer.” Although primary care providersare often chiefly concerned with acute health effects, the public is increasingly leading the way interms of interest in chronic and behavioral effects of pesticides (e.g., asthma, effects on IQ, etc.).
Workgroup members also frequently returned to the larger context in which this initiative isset. The group agreed that pesticides must continue to be seen in the context of environmentalhealth as a whole. The importance of making primary care providers aware of preventiveinformation along with diagnosis and treatment was continually stressed.
Finally, the group discussed support for the initiative. “There have been too many programsin government that just go away... If you don’t have the money at the time you need it, it fadesaway.” It is important that workgroup members go back to their organizations and discusshow the organizations can play a supporting role in implementing the initiative. The workgrouprecommended that the federal representatives develop a broad outline of resource needs andfederal commitments, as well as remaining needs for which extramural funding will be sought— from industry, professional associations, and possibly environmental foundations and trusts.
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Resources Workgroup MembershipCo-ChairsMark Robson, PhD, MPHEnvironmental and Occupational Health Sciences Institute, andRutgers University
Kevin Keaney, MA, MSOffice of Pesticide Programs, U.S. Environmental Protection Agency
FacilitatorSusan West, MPHThe National Environmental Education and Training Foundation, Inc.
MembersColin AustinMigrant Clinicians’ Network, andUniversity of North Carolina-Chapel Hill
Angelina Borbon, RNAlameda County Lead Poisoning Prevention Program
Barry Brennan, PhDAmerican Association of Pesticide Safety Educators, andExtension Pesticide Coordinator, University of Hawaii
Paul J. Brownson, MDThe Dow Chemical Company
Gerardo de Cosio, MDU.S.-Mexico Border Health Association
Susannah Donahue, MPHChildren’s Environmental Health Network
Gerry Eijkenmans, MD, MPHPan American Health Organization
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Scottie Ford, MAWest Virginia Department of Agriculture
Matthew Garabedian, MPHTexas Department of Health
Allen James, MBA, CAEElizabeth Lawder, BA (alternate)Responsible Industry for a Sound Environment
Linda Kanzleiter, M.Ps.Sc.Celeste Stalk (alternate)Pennsylvania Area Health Education Center, Milton S. Hershey Medical Center
Kathy Kirkland, MPHAssociation of Occupational and Environmental Clinics
Terry MillerNational Pesticides Telecommunications Network, andOregon State University
Rita MonroyNational Alliance for Hispanic Health (formerly NationalCoalition of Hispanic Health and Human Services Organizations)
Benjamin Ramirez, MD, MPH, FACOEMDuPont Company
Scott Ratzan, MD, MPAAcademy of Educational Development
Susan Rehm, MBAAmerican Academy of Family Physicians
Barbara SabolW.K. Kellogg Foundation
Roger F. Suchyta, MDGraham Newson (alternate)Jennifer Stevens (alternate)American Academy of Pediatrics
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Federal Agency RepresentativesElizabeth Blackburn, RNOffice of Children’s Health Protection, U.S. EPA
Jerome Blondell, MPH, PhDOffice of Pesticide Programs, U.S. EPA
Frank DavidoOffice of Pesticide Programs, U.S. EPA
Jeanne Goshorn, MSNational Library of Medicine
Ron Hoffer, MSOffice of Ground Water and Drinking Water, U.S. EPA
Ameesha Mehta, MPHOffice of Pesticide Programs, U.S. EPA
Donna Orti, MSAgency for Toxic Substances and Disease RegistryU.S. Department of Health and Human Services
Karen Pane, RN, MPA, CMCNHealth Resources and Services AdministrationU.S. Department of Health and Human Services
Dalton Paxman, PhDOffice of Disease Prevention and Health PromotionU.S. Department of Health and Human Services
Sherri UmanskyOffice of Ground Water and Drinking Water, U.S. EPA
Peter S. WoodAgricultural Marketing Service, U.S. Department of Agriculture
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Appendix C: FederalInteragency Planning Committee
Kevin KeaneyOffice of Pesticide ProgramsU.S. EPA1200 Pennsylvania Avenue NW (7506C)Washington, DC 20460Tel: (703) 305-5557 / Fax: (703) 308-2962Email: [email protected]
Ameesha Mehta, MPHOffice of Pesticide Programs, U.S. EPA1200 Pennsylvania Avenue NW (7506C)Washington, DC 20460Tel: (703) 305-6448 / Fax: (703) 308-2962Email: [email protected]
Delta Valente, MPAOffice of Pesticide ProgramsU.S. EPA1200 Pennsylvania Avenue NW (7506C)Washington, DC 20460Tel: (703) 305-7164 / Fax: (703) 308-2962Email: [email protected]
Jerome Blondell, PhDOffice of Pesticide ProgramsU.S. EPA1200 Pennsylvania Avenue NW (7509C)Washington, DC 20460Tel: (703) 305-5336 / Fax: (703) 305-5147Email: [email protected]
Ana Maria Osorio, MD, MPHOffice of Pesticide ProgramsU.S. EPA1200 Pennsylvania Avenue NW (7506C)Washington, DC 20460Tel: (703) 305-7891 / Fax: (703) 308-2962Email: [email protected]
Frank DavidoOffice of Pesticide ProgramsU.S. EPA1200 Pennsylvania Avenue NW (7502C)Washington, DC 20460Tel: (703) 305-7576 / Fax: (703) 305-4646Email: [email protected]
Diane SheridanOffice of Pollution Prevention and ToxicsU.S. EPA1200 Pennsylvania Avenue NW (7407)Washington, DC 20460Tel: (202) 260-3435 / Fax: (202) 260-2347Email: [email protected]
Elizabeth Blackburn, RNOffice of Children’s Health ProtectionU.S. EPA1200 Pennsylvania Avenue NW (1107)Washington, DC 20460Tel: (202) 260-7935 / Fax: (202) 260-4103Email: [email protected]
U.S. Environmental Protection Agency
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Ron HofferOffice of Ground Water and Drinking WaterUS. EPA1200 Pennsylvania Avenue NW (4607)Washington, DC 20460Tel: (202) 260-7096 / Fax: (202) 260-3762Email: [email protected]
Marjorie C. JonesOffice of Ground Water and Drinking WaterU.S. EPA1200 Pennsylvania Avenue NW (4601)Washington, DC 20460Tel: (202) 260-4152 / Fax: (202) 260-4383Email: [email protected]
Sherri UmanskyOffice of Ground Water and Drinking WaterU.S. EPA1200 Pennsylvania Avenue NW (4607)Washington, DC 20460Tel: (202) 260-0432 / Fax: (202) 401-6135Email: [email protected]
U.S. EPA Regional LiaisonsJane HortonPesticides Section (4APT-PS)U.S. EPA, Region 461 Forsyth St., SWAtlanta, GA 30303Tel: (404) 562-9012 / Fax: (404) 562-8972Email: [email protected]
Don BaumgartnerPesticides Section (DRT-8J)U.S. EPA, Region 577 West Jackson BoulevardChicago, IL 60604-3590Tel: (312) 886-7835Fax: (312) 353-4788Email: [email protected]
Amy MyszU.S. EPA, Region 577 W. Jackson Blvd. (DT-8J)Chicago, IL 60604Tel: (312) 886-0224 / Fax: (312) 353-4788Email: [email protected]
Allan WelchPesticides Section (AT-083)U.S. EPA, Region 101200 Sixth AvenueSeattle, WA 98101Tel: (206) 553-1980 / Fax: (206) 553-8338Email: [email protected]
U.S. Department of Healthand Human ServicesBarry Stern, MPHBureau of Health ProfessionsHealth Resources & Services Administration5600 Fishers Lane (8C-09)Rockville, MD 20857Tel: (301) 443-6758 / Fax: (301) 443-0650Email: [email protected]
Karen Pane, RN, MPA, CMCNOffice of Planning, Evaluation and LegislationHealth Resources & Services Administration5600 Fishers Lane (14-36)Rockville, MD 20857Tel: (301) 443-1128 / Fax: (301) 443-9270Email: [email protected]
Barbara Brookmyer, MD, MPHBureau of Health Professions,Division of MedicineHealth Resources & Services Administration5600 Fishers Lane (9A-27)Rockville, MD 20857Tel: (301) 443-1468 / Fax: (301) 443-8890Email: [email protected]
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Ruth Kahn, DNScBureau of Health Professions,Division of MedicineHealth Resources & Services Administration5600 Fishers Lane (9A-27)Rockville, MD 20857Tel: (301) 443-6823 / Fax: (301) 443-8890Email: [email protected]
Madeleline Hess, PhD, RNBureau of Health Professions,Division of NursingHealth Resources & Services Administration5600 Fishers Lane (9-35)Rockville, MD 20857Tel: (301) 443-6336 / Fax: (301) 443-8586Email: [email protected]
Joan Weiss, PhD, RN, CRNPBureau of Health Professions,Division of NursingHealth Resources & Services Administration5600 Fishers Lane (9-36)Rockville, MD 20857Tel: (301) 443-5486 / Fax: (301) 443-8586Email: [email protected]
David D. Hanny, PhD, MPHBureau of Health ProfessionsDivision of Interdisciplinary,Community-Based ProgramsHealth Resources & Services Administration5600 Fishers Lane (9105)Rockville, MD 20857Tel: (301) 443-0024 / Fax: (301) 443-0162Email: [email protected]
Eva MontoyaBureau of Primary Health Care,Migrant Health ProgramHealth Resources & Services Administration4350 East West HighwayBethesda, MD 20814Tel: (301) 594-4305 / Fax: (301) 594-4997Email: [email protected]
Cassandra LylesOffice of Rural Health PolicyHealth Resources & Services Administration5600 Fishers Lane (9-05)Rockville, MD 20857Tel: (301) 443-7321 / Fax: (301) 443-2803Email: [email protected]
Geoffrey Calvert, MD, MPHNational Institute ofOccupational Safety & Health4676 Columbia Parkway, R-21Cincinnati, OH 45226Tel: (513) 841-4448 / Fax: (513) 841-4489Email: [email protected]
Rosemary Sokas, MD, MOHNational Institute ofOccupational Safety & Health200 Independence Avenue SW, Room 715-HWashington, DC 20201Tel: (202) 401-0721 / Fax: (202) 693-1647Email: [email protected]
Dalton Paxman, PhDOffice of Disease Preventionand Health PromotionDepartment of Health and Human Services200 Independence Avenue, SW, Room 738-GWashington, DC 20201Tel: (202) 205-5829 / Fax: (202) 205-9478Email: [email protected]
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Donna Orti, MSAgency for Toxic Substances & Disease RegistryDepartment of Health and Human Services1600 Clifton Road (E-42)Atlanta, GA 30333Tel: (404) 639-6217 / Fax: (404) 639-6208Email: [email protected]
U.S. Department of AgriculturePeter S. WoodPesticide Records BranchUSDA Agricultural Marketing Service8700 Centreville Road, Suite 202Manassas, VA 20110Tel: (703) 330-7826 / Fax: (703) 330-6110Email: [email protected]
Larry Olsen, PhDUSDA Cooperative State Research,Education, and Extension ServiceInterim National Program Leader PAT1400 Independence Ave. SWAG Mail Stop 2220Washington, DC 20250Tel: (202) 401-4201 / Fax: (202) 401-4888Email: [email protected]
U.S. Department of LaborMike HancockWage and Hour DivisionU.S. Department of Labor200 Constitution Ave. NW, Room S-3510Washington, DC 20210Tel: (202) 219-7605 / Fax: (202) 219-5122Email: [email protected]
Other OrganizationsSusan T. West, MPHThe National Environmental Education& Training Foundation1707 H Street, NW, Suite 900Washington, DC 20006Tel: (202) 261-6473 / Fax: (202) 261-6464Email: [email protected]
Jennifer Bretsch, MSThe National Environmental Education& Training Foundation1707 H Street, NW, Suite 900Washington, DC 20006Tel: (202) 261-6470 / Fax: (202) 261-6464Email: [email protected]
Amy E. Brown, PhDAmerican Association ofPesticide Safety EducatorsDept. of Entomology, Univ. of MarylandCollege Park, MD 20742Tel: (301) 405-3928 / Fax: (301) 314-9290Email: [email protected]
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