By Eldridge, Deanna Tenkate, Thomas D
Abstract Even though environmental health is widely considered to be an integral component of disaster management, limited research on this topic has been conducted. Using a qualitative approach, the authors conducted in-depth interviews of practitioners in Queensland, Australia, to explore the role of environmental health in disaster management and determine how those internal and external to the profession perceive this role. The major themes that emerged described a process in which the “view of health” is socially constructed, and this process is instrumental in shaping perception of the environmental health role in disaster management. The authors also found that the role of environmental health in disaster management is experiencing renegotiation due to a complex process of challenging the socially constructed view of health, raising the profile of the profession, and achieving increased representation in disaster management. Ultimately, increased recognition and a heightened profile of environmental health will result in a more effective disaster management system and will carry over into day- to-day activities.
Introduction
In recent years, disaster management has been at the forefront of discussions in Australia and many other countries. This is in part due to a realization that the previous arrangements may not have been adequate to meet the range of emerging threats. The terrorist attacks of September 11, 2001; the Bali bombings in 2002 and 2005; the London bombings in 2005; and fears of bioterrorism have resulted in a changed environment for disaster management in Australia and internationally (Bradt, Abraham, & Franks, 2003; Burkle, 2006; Caldicott & Edwards, 2002; Fisher & Burrow, 2003; Noji, 2001; Vinen, 2003).
Disaster management structures must continue to be effective for natural disasters, such as cyclones, bushfires, tsunamis, infrastructure or technological failure, and heat waves (Abrahams, 2001; Emergency Management Australia, 2005). These structures also need to ensure that appropriate mechanisms are in place to respond to emerging diseases, such as avian influenza, SARS, and the threat of pandemic influenza (Loeb, 2004; Srinivasan et al., 2004). The changing landscape in disaster management means that new hazards must be identified and protected against in addition to existing hazards, requiring extensive reviews of disaster management structures (Armstrong, 2003; Berg, 2004; Caldicott & Edwards, 2002; Emergency Management Australia, 2003).
Despite the integral role of environmental health in disaster management, the specific role of environmental health practitioners in disaster management was rarely investigated until after the terrorist attacks of September 11, 2001. Since then, a substantial amount of literature has emerged; however, this has consisted primarily of descriptive accounts, opinion pieces such as editorials and interviews, and reports (Berg, 2004; Fabian, 2002; Fabian, 2004; Forsting, 2004; Lyman, 2003). Most of this literature focuses on the roles of environmental health professionals in the context of terrorism or bioterrorism; however, the emerging themes can be applied to many large-scale disaster situations (Fabian, 2002; Forsting, 2004; Khan, Morse, & Lillibridge, 2000; Noji, 2005; Noji & Toole, 1997).
It is clear from the literature that a number of issues for environmental health in relation to disaster management require further research. The most common theme is that ambiguity exists about the role of environmental health in disaster management, particularly in its distinction from the broader roles of public health. This ambiguity is exacerbated by a lack of research on this topic (Fabian, 2002; Forsting, 2004; Lyman, 2003). Other themes that have emerged relating to environmental health generally and in the context of disaster management specifically include the following:
* the professionalization of environmental health (Brimblecombe, 2003; Kotchin, 1997; Roberts, 1996);
* the representation, profile, and visibility of the environmental health discipline (Berg, 2004; Emergency Management Australia, 2003; Fabian, 2002; Fabian, 2004; Logue, 1996; Lurle, Wasserman, & Nelson, 2006; Lyman, 2003);
* debate surrounding the separation of environmental health from public health (Kotchin, 1993; Kotchin, 1997; Leggat, 2003; Logue, 1996);
* the power and politics involved in role negotiation (Berg, 2004; Bashir, Lafronza, Fraser, Brown, & Cope, 2003); and
* the top-down approach to constructing disaster plans (Bashir et al., 2003; Rasmussin & Jansen, 1998).
Given the lack of research into an increasingly important topic, we conducted a rigorous qualitative study during 2005 in Queensland, Australia, to explore the role of the environmental health discipline in relation to disasters and how others perceive this role. This study also explored the broader role of environmental health and the perceptions of both environmental health practitioners and those external to environmental health.
Methods
This research employed a rigorous qualitative approach in which in-depth interviews were conducted with 10 experienced practitioners from the areas of disaster management, environmental health, and public health.
Qualitative Methodology
This study was grounded in the epistemologica! principles of social constructionism and guided by the theoretical tenets of symbolic interactionism. The research framework is depicted in Figure 1. Social constructionist inquiry is concerned with discovering how individuals and groups create their perceived realities (Gergen, 2003) and was applied in this study because the focus was on the function of social processes in shaping the role of environmental health in disaster management. Furthermore, people’s knowledge of environmental health dictates how they act towards and within the environmental health profession.
Symbolic interactionism is a theoretical perspective that provides a link between the examination of the social processes that shape knowledge and the ways in which human beings act upon, reproduce, and modify that knowledge. The foremost objective of symbolic interactionism is to portray and understand the construction of meaning.
A number of criticisms of symbolic interactionism, exist, however, with one-that it neglects methodological issues- particularly relevant to this study. This criticism led to the development of grounded theory, which is a systematic method for organization and analysis of qualitative data (Crotty, 1998; Liamputtong & Ezzy, 2005). Grounded theory was applied in this study, as it provides researchers with a way to study the behavior and interaction of humans, in order to “conceptualize behavior in complex situations, to understand unresolved or emerging social problems, and to understand the impact of new ideologies (Chenitz & Swanson, 1986).”
Sampling and Recruitment
Participants for this study were recruited through the combined use of two sampling methods: purposive and snowball sampling. Purposive sampling is a deliberately non-random method of participant recruitment, ft is commonly used in qualitative research and is particularly useful for obtaining a sample of a group of people with a similar, specific characteristic for study and when experience of a phenomenon is of interest (Bowling, 2002; Streubert & Carpenter, 1999). Snowball sampling occurs where recruited participants recommend further potential participants with in-depth knowledge of the research subject matter. This method was useful in this study, as the population of interest is well-networked, and it would otherwise have been difficult to identify and access appropriate participants.
Sample size determination is a complex issue in qualitative research and essentially one of breadth versus depth of data, balanced with available resources. Some researchers advocate the idea of continuing data collection until saturation of themes occurs or where no new themes are emerging (Glaser & Strauss, 1967; Strauss & Corbin, 1998; Streubert & Carpenter, 1999). However, others argue that the concept of saturation is flawed because no certainty can be attained that new participants interviewed at a different time would not reveal new themes; thus, the idea of saturation is a myth (Morse, Barrett, Mayan, Olson, & Spiers, 2002; Streubert & Carpenter, 1999). In this study, data collection ceased after ten interviews, when the data had sufficient depth to explore the dimensions of the phenomenon of interest.
Participant Demographics
fn this study, the participants averaged 22.5 years of experience in their respective fields, with some having extensive international experience either through aid organizations or the military. The sample included four environmental health officers, a public health medical officer, public health and environmental health managers, and a disaster management coordinator from both local and state levels of government.
Data Collection and Analysis
In-depth interviews were conducted, using a semi-structured, face- to-face format, interviews lasted between 40 and 60 minutes and were tape recorded and transcribed for analysis. The analysis process proceeded as follows: transcription of interviews; participant validation; preparation of transcriptions for analysis; open, axial, and selective coding, using grounded theory methods described by Strauss and Corbin (1988); and thematic analysis. Ethics
Ethical clearance was obtained from the Queensland University of Technology human research ethics committee and the Queensland health human research ethics committee.
Results and Discussion
The data analysis showed perception of the environmental health role in disaster management as ultimately being a result of the socially constructed meaning of “health,” which is the view people external to public health and environmental health hold. As demonstrated in Figures 2 and 3, two primary processes lead to this occurrence, and the key themes that emerged are described in detail in the following sections. The results also identified a disjuncture between environmental health practitioners and others involved in disaster management about the role of environmental health in disasters.
Relationship of Environmental Health and Public Health
Although most of the participants were working in environmental health, they generally referred to themselves broadly as public health practitioners. This view therefore affects how environmental health practitioners and other disciplines involved in disaster management see the role of environmental health and is important when considering the results, particularly as some debate exists in the literature regarding a need to clarify the distinction between environmental health and public health (Kotchian, 1997; Leggat, 2003).
View of Health
This emerged as the core category, representing how the role of environmental health is defined and also how the role is currently being negotiated. The social construction of “health” and everything represented by “health” in disaster management was found to occur through a complex process of interaction between four concepts: visibility, politics, public perception, and recognition (see Figure 2). The resulting meaning that is attributed to health determines the role of environmental health as those external to the environmental and public health professions perceive it.
The view of health has significant ramifications for the interaction of environmental health in disaster management. People external to public health and environmental health in Queensland view health as both clinical, relating to the observation and treatment of patients; and medical, relating to the practice of medicine through health maintenance or treatment of disease. This view focuses on individual patients. The “alternative” view of health is that health has a dual role: the medical role just described and the role of maintaining the health of the population. These differing views of health result in different outcomes for the role and profile of environmental health.
Participants indicated that if the clinical/medical view was dominant, the public health response to disasters would be neglected in favor of a medical response, which would cause frustration for the environmental health personnel involved. Therefore, a common theme was that the medical view of health that seems to dominate in Queensland has relegated public health and environmental health to second place.
Visibility
The concept of visibility relates to public perception and recognition of the profession. The participants recognized a strong association between the low visibility of the profession and the clinical/medical view of health.
Due to this lack of visibility, participants viewed the environmental health role as lacking significance, often because of its lack of immediately observable or measurable results and the subsequent lack of attention and value attributed to the profession by both the public and government agencies. As such, two ideas strongly related to visibility were public perception and recognition. These concepts have a direct influence on the perception of health, and thus the environmental health role.
Public Perception
Since the public primarily interacts with the medical side of the health system, this shapes their perception of health as relating to the treatment of health-related problems on an individual basis. This leads to a lack of recognition of environmental health, given the public’s influence on political decision making.
Additionally, participants believed that a disconnect existed between environmental health practitioners and the public about environmental health’s role. This was primarily attributed to the terminology that is applied to the profession, with confusion between such concepts as the “health of the environment” and “environmental health.” Berg (2004) sees this misrepresentation as an opportunity for environmental health, due to the increasing emphasis that environmental groups place on human health and the higher profile of these groups, compared to the environmental health field. The advantage, then, is in the opportunity for the environmental health field to state its case to the public and communicate the importance of the field.
Politics
A common theme was that public perception ultimately shapes the political view of health. Therefore, as the medical view dominates the public perception of health, this shapes the focus of provisions by state governments. This relationship between the view of health, public perception, and politics is clearly articulated by one participant: “If the public says you’re not doing enough about health, the Minister [would] be more likely to say ‘Well, more hospital beds,’ or something like that.”
This primacy of the medical view of health translates into lack of recognition of the environmental health role and the subsequent lack of importance ascribed to it. The political conceptualization of health is also inherent in the structures of health organizations, where an unequal distribution of resources favors medical services over public health services.
Recognition
The concept of recognition is strongly tied to visibility and public perception. Participants pointed out that the lack of recognition of environmental health under normal conditions can become exacerbated in disaster situations, despite some recent improvements. If the role of environmental health has not been recognized prior to a disaster, this creates specific problems in relation to disaster response.
Environmental health practitioners with greater experience in disaster management, however, tended to experience less difficulty with being recognized. As such, their interaction in the field had resulted in the renegotiation of their role by others in disaster management. Unfortunately, this recognition did not necessarily translate to all levels of disaster management or benefit all environmental health practitioners advocating for involvement in the field. Disaster management therefore represents a prime area of environmental health activities in which to raise the profile of environmental health, with benefits potentially flowing on into day- to-day activities.
Representation
In the process of renegotiating their role in disaster management, the environmental health profession in Queensland has sought increased representation in the field. The primary way in which participants felt that their profile had been raised was due to increased representation of environmental health and public health on disaster management groups (DMGs) at the local and district levels (see Figure 4). In Queensland, these DMGs are an integral front-line component of the disaster management system and consist of high-level local representatives from key agencies. Under previous long-standing arrangements, however, only medically- orientated personnel were the “health” representatives on these DMGs and thus the environmental and public health role was not highly recognized or valued.
Improved DMG representation, therefore, has provided increased networking and relationship-building opportunities and also has connotations of authority and influence through which environmental health can achieve increased effectiveness in a disaster. In addition, the participants considered the recent process of developing a State Health Emergency Response Plan (SHERP) in Queensland (see Figure 4) to have been integral to a renegotiation of the role of environmental health in disaster management. Again, this was principally through interaction with a number of agencies involved in disaster management, resulting in a higher public health profile. It is then through this process that the importance of the “alternative” view of health, encompassing both medical and public health, is able to be emphasized.
Conclusion
This study explored the role of environmental health in disaster management and how environmental health practitioners and others involved in disaster management perceive this role in Australia, and particularly in Queensland. The study found that the environmental health role in disaster management is primarily a result of the socially constructed view of health. The traditional “medical” view of health has resulted from a complex interplay of the concepts of visibility, public perception, politics, and recognition. As a result of this view of health, public health, inclusive of environmental health, has been relegated to second place behind medical health services within disaster management. Environmental health in particular has therefore had a very low profile.
In Queensland, representation on DMGs and the SHERP process have improved the profile of environmental health practitioners and environmental health in general. With representation on local and district DMGs, the value of environmental health is being increasingly recognized. Authority and influence also come with DMG representation, due to the development of relationships with those in charge of coordinating disaster response efforts. Ultimately, the heightened environmental health profile and increasing recognition by others involved in disaster management will result in a more effective and appropriate response to disaster situations. The results of this study highlight how disaster management has provided an opportunity for the environmental health profession to raise its profile and renegotiate the role of environmental health in disaster management. The results also demonstrate how the benefits of a higher profile, greater recognition, and representation in the disaster management arena can carry over to normal day-to-day activities. Environmental health practitioners are therefore encouraged to have greater involvement in disaster management, as this provides opportunities to develop relationships with high- level personnel from other agencies, leading to role renegotiation and the ascribing of importance to the role played by environmental health in both disaster and non-disaster situations.
REFERENCES
Abrahams, J. (2001). Disaster management in Australia: The national emergency management system. Emergency Medicine Australasia, 13, 165-173.
Armstrong, E (2003). Alert but not alarmed: Australia’s health system prepares. Australian Nursing Journal, 10, 22-24.
Bashir, Z., Lafronza, V., Fraser, M.R., Brown, C.K., & Cope, J.R. (2003). Local and state collaboration for effective preparedness planning. Journal of Public Health Management and Practice, 9, 344- 351.
Berg, R. (2004). Terrorism response and the environmental health role: The million-dollar (and some) question. Journal of Environmental Health, 67(2), 29-39.
Bowling, A. (2002). Research methods in health: Investigating health and health services (2nd ed., pp. 187-188). Buckingham, UK: Open University Press.
Bradt, D.A., Abraham, K., & Franks, R. (2003). A strategic plan for disaster medicine in Australasia. Emergency Medicine Australasia, 15, 271-282.
Brimblecombe, P. (2003). Historical perspectives on health: The emergence of the sanitary inspector in Victorian Britain. Journal of the Royal Society for the Promotion of Health, 123, 124-131.
Burkle, F.M. (2006). Globalization and disasters: Issues of public health, state capacity, and political action. Journal of International Affairs, 59, 241-265.
Caldicott, D.G.E., & Edwards, N.A. (2002). The global threat of terrorism and its impact on Australia. Emergency Medicine Australasia, 14, 218-229.
Chenitz, W.C., & Swanson, J.M. (1986). From practice to grounded theory: Qualitative research in nursing (p.7). Menlo Park, CA: Addison Wesley.
Crotty M. (1998). The foundations of social research: Meaning and perspective in the research process (p. 78). St. Leonards, Australia: Allen and Unwin.
Emergency Management Australia. (2003). Mapping the way forward for large-scale urban disaster management in Australia: Building on the lessons from September 11, 2001. Retrieved April 13, 2005, from http://www.ema.gov.au/agd/EMA/rwpattach.nsf/VAP/ (63F2fBC6A4528BAE4CED2F9930C45677)~EMALessonsLearntbookletfinal.pdf/ $file/EMALessonsLearntbookletfinal.pdf
Emergency Management Australia. (2005). Concepts and principles in emergency management. Retrieved May 31, 2005, from http:// www.ema.gov.au/agd/EMA/emaInternet.nsf/Page/
ions_Menu_Principles_Concepts_and_Principles_Concepts_and_Principles
Fabian, N. (2002). Post September 11: Some reflections on the role of environmental health in terrorism response. Journal of Environmental Health, 64(9), 78, 77, 65.
Fabian, N. (2004). It can be done-making the invisible visible. Journal of Environmental Health, 67(2), 70, 51.
Fisher, D., & Burrow, J. (2003). The Bali bombings of 12 October, 2002: Lessons in disaster management for physicians. Internal Medicine Journal, 33, 125-126.
Forsting, S.L. (2004). Environmental health professionals and emergency preparedness: Canadian perspectives. Journal of Environmental Health, 67(4), 31-35.
Gergen, K.J. (2003). Knowledge as socially constructed. In M. Gergen & K.J. Gergen (Eds.), Social construction: A reader (pp. 1- 10). London: Sage Publications.
Glaser, B.G., & Strauss, A.L. (1967). The discovery of grounded theory: Strategies for qualitative research (pp. 61-62). New York: Aldine De Gruyter.
Khan, A.S., Morse, S., & Lillibridge, S.R. (2000). Public-health preparedness for biological terrorism in the USA. Lancet, 356, 1179- 1182.
Kotchian, S.B. (1993). Environmental leadership in a public health agency. Journal of Environmental Health, 55(5), 60-61.
Kotchian, S.B. (1997). Perspectives on the place of environmental health and protection in public health and public health agencies. Annual Review of Public Health, 18, 245-259.
Leggat, P (2003). Environmental health: Global initiatives and new analytical approaches. Journal of Rural and Remote Environmental Health, 2(2), 36-37.
Liamputtong, P., & Ezzy D. (2005). Qualitative research methods (2nd ed., pp. 265-267). Melbourne: Oxford University Press.
Loeb, M. (2004). Severe acute respiratory syndrome: Preparedness, management and impact. Infection Control and Hospital Epidemiology, 25, 1017-1019.
Logue, J.N. (1996). Disasters, the environment, and public health: Improving our response. American Journal of Public Health, 86, 1207-1210.
Lurle, N., Wasserman, J., & Nelson, CD. (2006). Public health preparedness: Evolution or revolution? Health Affairs, 25, 935-945.
Lyman, F. (2003). Messages in the dust: Lessons learned, post-9/ 11, for environmental health. Journal of Environmental Health 66(5), 31.
Morse, J.M., Barrett, M., Mayan, M., Olson, K. & Spiers, J. (2002). Verification strategies for establishing reliability and validity in qualitative research. International Journal of Qualitative Methods, 1(2), Article 2. Retrieved April 19, 2005, from http://www.ualberta.ca/~ijqm/
Noji, E.K. (2001). Bioterrorism: A new global environmental health threat. Global Change Human Health, 2, 46-53.
Noji, E.K. (2005). Public health in the aftermath of disasters. British Medical Journal, 330, 1379-1381.
Noji, E.K., & Toole, M.J. (1997). The historical development of public health responses to disasters. Disasters, 21, 366-376.
Rasmussen, J., & Jensen, S. (1998). Incident management systems: A means of enhancing coordination, communication and decision making in a disaster. National Emergency Management, 13(3), 13-15, 17-18.
Roberts, R. (1996). EHOs do have ancestors! Journal of Environmental Health, 59(5), 20.
Srinivasan, A., McDonald, L.C., Jernigan, D., Helfand, R., Ginsheimer, K., Jernigan, J., Chiarello, L., Chinn, R., Parashar, U., Anderson, L., Cardo, D., & SARS Healthcare Preparedness and Response Plan Team. (2004). Foundations of the severe acute respiratory syndrome preparedness and response plan for healthcare facilities. Infection Control and Hospital Epidemiology, 25, 1020- 1025.
Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Grounded theory procedures and techniques (2nd ed.). Thousand Oaks, CA: Sage Publications.
Streubert, H.J., & Carpenter, D.R. (1999). Qualitative research in nursing: Advancing the humanistic perspective (2nd ed.) Philadelphia: Lippincott.
Vinen, J. (2003). Bali: A wake-up call. Internal Medicine Journal, 33(3), 71-73.
Deanna Eldridge
Thomas D. Tenkate, Dr.P.H.
Corresponding Author: Thomas D. Tenkate, Senior Lecturer in Environmental Health, QUT School of Public Health, Victoria Park Road, Kelvin Grove, QLD, Australia 4059. E-mail: [email protected].
Copyright National Environmental Health Association Sep 2008
(c) 2008 Journal of Environmental Health. Provided by ProQuest LLC. All rights Reserved.
