Pesticides and National Strategies for Health Care Providers: Draft Implementation Plan

Transcription

1 Pesticides and National Strategies for Health Care Providers: Draft Implementation Plan Support for this project was made possible through Cooperative Agreement CR between the Office of Pesticide Programs of the U.S. Environmental Protection Agency and The National Environmental Education & Training Foundation.

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3 Acknowledgments The successful development of this Implementation Plan would not have been possible without the efforts of a large number of dedicated people and organizations. The Expert Panel members gave 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 has produced this Plan. The workgroups were also expertly guided by their co-chairs, specifically Andrea Lindell and Ameesha Mehta (Education Workgroup), Karen Pane and Bonnie Rogers (Practice Work Group), and Mark Robson and Kevin Keaney (Resources Work Group). The Federal Interagency Planning Committee has contributed many hours of guidance and oversight to the development of the Plan, and significantly helped to organize the Expert Panel and the three workgroups. The Committee also continues to 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 part of a larger cooperative agreement for the entire initiative between EPA s Office of Pesticide Programs and The National Environmental Education & Training Foundation (NEETF). Susan West, Senior Director for Health & Environment Programs at NEETF, has managed this cooperative agreement, including the planning and facilitation of the Expert Panel and workgroup meetings, the drafting of this Plan, and setting the overall vision for this initiative in collaboration with Ameesha Mehta at EPA. In addition, a team 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 the workgroup 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, kept the Plan s development on track and moving forward. Kevin Keaney, Chief of the Certification and Worker 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 agency partners 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 pesticides@neetf.org. Photo credits: Photos on pages 13, 18, and 41: Steven Delaney, EPA. iii

4 Federal Interagency Planning Committee U.S. Environmental Protection Agency Office 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 Liaisons Jane Horton Region 4 Don Baumgartner Region 5 Amy Mysz Region 5 Allan Welch Region 10 U.S. Department of Health and Human Services Health 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 Agriculture Agricultural Marketing Service Peter S. Wood, MS Cooperative State Research, Education, and Extension Service Larry Olsen, PhD U.S. Department of Labor Mike Hancock Other Organizations The 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 iv

5 Expert Panel and Workgroup Members Sheila Brown Arbury, RN, MPH Association of Occupational and Environmental Clinics Colin Austin Migrant Clinicians Network, and University of North Carolina-Chapel Hill Joni Berardino, MS, LSW National Center for Farmworker Health Angelina Borbon, RN Alameda County Lead Poisoning Prevention Program Barry Brennan, PhD American Association of Pesticide Safety Educators, and Extension Pesticide Coordinator, University of Hawaii Amy Brown, PhD American Association of Pesticide Safety Educators, and University of Maryland-College Park Paul J. Brownson, MD The Dow Chemical Company Candace Burns, PhD, ARNP National Organization of Nurse Practitioner Faculties, and University of South Florida College of Nursing Joan Spyker Cranmer, PhD University of Arkansas Medical School Miriam Cruz Equity Research Shelley Davis Farmworker Justice Fund, Inc. Gerardo de Cosio, MD U.S.-Mexico Border Health Association Susannah Donahue, MPH Children s Environmental Health Network J. Ward Donovan, Jr., MD, FACEP American College of Emergency Physicians, Pennsylvania University Poison Center, and Milton S. Hershey Medical Center Gerry Eijkenmans, MD, MPH Pan American Health Organization Joe Fedoruk, MD, DABT, CIH American College of Occupational and Environmental Medicine Kesner Flores, EMT Cortina Indian Rancheria, Wintum Environmental Protection Agency Scottie Ford, MA West Virginia Department of Agriculture Jose Garcia Equity Research Matthew Garabedian, MPH Texas Department of Health Jeanne Goshorn, MS National Library of Medicine Harold Harlan, PhD National Pest Control Association Barbara Hatcher, PhD, MPH, RN American Public Health Association Rugh Henderson, MD, MPH North American Agromedicine Consortium, Pennsylvania Agromedicine Program, and Penn State University College of Medicine Michael Hodgman, MD National Rural Health Association, and Bassett Healthcare/NY Center for Agricultural Medicine and Health Allen James, MBA, CAE Elizabeth 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, MPH NIOSH Agricultural Health and Safety Centers, and University of Washington Kathy Kirkland, MPH Association of Occupational and Environmental Clinics Andrea Lindell, DNSc, RN American Association of Colleges of Nursing, and University of Cincinnati College of Nursing Ann Linden, CNM, MSN, MPH American College of Nurse Midwives John McCarthy, PhD American Crop Protection Association v

6 Claudia Miller, MD University of Texas Health Science Center San Antonio Mark Miller, MD American Academy of Pediatrics Mary Miller, MN, ARNP American Nurses Association, and Washington State Department of Labor and Industries Terry Miller National Pesticides Telecommunications Network, and Oregon State University Rita Monroy National Alliance for Hispanic Health (formerly National Coalition of Hispanic Health and Human Services Organizations) Karen Mountain, MBA, MSN, RN Migrant Clinicians Network Diane Mull Association of Farmworker Opportunity Programs Madaleine Ochinang, MS Formerly with the Consortium for Environmental Education in Medicine Patrick O Connor-Marer, PhD American Association of Pesticide Safety Educators, University of California Statewide IPM Project, and University of California Agricultural Health and Safety Center Marcia Allen Owens, JD Minority Health Professions Foundation Dennis Penzell, DO, FACP Suncoast Community Health Centers, Inc. Annette Perez, RNC, MSN, CNM, PhD American College of Nurse Midwives, and University of Texas-El Paso, College of Health Sciences John Pickle, MSEH Weld County Health Department Greeley, CO Ana Maria Puente Bureau of Primary Health Care, Border Health, Health Resources and Services Administration Benjamin Ramirez, MD, MPH, FACOEM DuPont Company Scott Ratzan, MD, MPA Academy of Educational Development Susan Rehm, MBA American Academy of Family Physicians J. Routt Reigart, MD Medical University of South Carolina, Department of Pediatrics Mark Robson, MD, MPH Environmental and Occupational Health Sciences Institute, and Rutgers University George C. Rodgers, Jr, MD, PhD American Association of Poison Control Centers, and University of Loiusville School of Medicine Bonnie Rogers, RN, DrPH, COHN-S, FAAN American Association of Occupational Health Nurses, and University of North Carolina-Chapel Hill School of Public Health Rachel Rosales, MSHP Texas Department of Health Elaine R. Rubin, PhD Association of Academic Health Centers Barbara Sabol W. K. Kellogg Foundation Barbara Sattler, RN, DrPH University of Maryland School of Nursing Jackilen Shannon, PhD Council of State and Territorial Epidemiologists, and Texas Department of Health Cathy Simpson, MD Wayne State University School of Medicine Gina Solomon, MD, MPH Natural Resources Defense Council Elisabeth Spector, MD, MPH American Academy of Family Physicians Roger F. Suchyta, MD Graham Newson (alternate) Jennifer Stevens (alternate) American Academy of Pediatrics Greg P. Thomas, PA-C American Academy of Physician Assistants Leonel Vela, MD Migrant Health Advisory Council, and Texas Tech Health Sciences Center Sheldon Wagner, MD National Pesticide Medical Monitoring Program, and Oregon State University John Wheat, MD, MPH North American Agromedicine Consortium, and University of Alabama at Birmingham, School of Medicine vi

7 Contents Executive Summary... 1 Vision, Expected Outcomes, and Evaluation Making the Case Target Audience Framework of the Plan: A Three-Pronged Strategy Educational Settings Practice Settings Resources and Tools Conclusion References Glossary Appendix A: Expert Panel Proceedings Appendix B: Summary Proceedings from Workgroups Appendix C: Federal Interagency Planning Committee

8 List of Exhibits Tables 1 Components of the Implementation Plan Initiative Work Products Pesticides Most Often Implicated in Symptomatic Illnesses, Targets, Populations Served, Practice Settings Stages of Change Model Proposed Competencies for Educational Institutions Proposed Design of Faculty Champions Project Expected Practice Skills Preliminary Outline Figures 1 Framework of the Implementation Plan Projected Timeline for Accomplishing Implementation Plan Stages of Change and Implementation Plan Components... 31

9 Executive Summary Pesticides are ubiquitous in our society in both agricultural and urban sectors. We use pesticides in our homes, in our workplaces, and in our communities. Due to the widespread dissemination of pesticides, and the potential for related illness and injury (especially among farmworkers and pesticide handlers), health care providers should be prepared to recognize, manage and prevent pesticide-related health conditions in their patients and communities. Communities expect that their primary care providers will be prepared to deal 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 National Strategies for Health Care Providers, sets out a strategic direction for the nation to improve the recognition, management, and prevention of pesticide-related health conditions. It will lead to health improvements in both agricultural and urban sectors. The Plan s vision is for all primary care providers on the front lines of our health care system to: Possess a basic understanding of the health effects associated with pesticide exposures as well as broader environmental exposures; and 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 includes both short and long-term components. The Plan will be used to build national consensus on this issue and to gain funding and resource support to implement and evaluate the entire initiative. The initiative, Pesticides and National Strategies for Health Care Providers, was created by the U.S. Environmental Protection Agency (EPA) in collaboration with the U.S. Department of Health and Human Services (DHHS), the U.S. Department of Agriculture (USDA), the U.S. Department of Labor (DOL), and The National Environmental Education & Training Foundation (NEETF). From the outset, this national interagency initiative has been conceived of as a long-term effort. Sustained funding will be needed to ensure the success of the Plan, and multi-stakeholder involvement is necessary from federal agencies, academic institutions, professional organizations, foundations, farmworker and farm groups, industry and trade associations. 1

10 This Plan focuses on pesticides as an important model which can easily be expanded to incorporate 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 other national 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 reflects the 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 to address this issue. It is hoped that this Plan will pave the way for the strategic next steps needed 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 be showcased at a national forum for health care providers scheduled for 2001 in Washington, DC. The Initiative s Driving Forces This initiative received its impetus from a number of sources. The Worker Protection Standard A primary contributor is EPA s Worker Protection Standard, designed to reduce pesticide exposure to agricultural workers, mitigate exposures that occur, and inform agricultural employees of the hazards of pesticides. The regulation, implemented in 1995, mandates that millions of farmers, pesticide applicators, and farmworkers be educated for such efforts. This in 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 held nine public meetings to evaluate the progress of implementation and hear the experience of the people most affected by the regulation. One clear message from the public meetings was the need to improve the recognition, diagnosis, and management of adverse health effects from pesticide exposures on the part of all primary care providers of the health care community. Although the primary populations affected by pesticides are the 3 to 4.5 million farmworkers in America and the million or more pesticide applicators, pesticides are widely used in the urban sector. Urban and suburban exposures to pesticides through lawn care products and insecticides in the home and workplace are affecting the population at large. Health care providers in urban settings are even less likely to think pesticides in taking patient histories or diagnosing illnesses. 2

11 Other Forces In the field of environmental health, the need for improvements in health care provider training has been expressed by health professional groups, academic institutions, as well as government and community organizations. In 1994, the American Medical Association adopted a resolution urging Congress, government agencies, and private organizations to support improved strategies for the assessment and prevention of pesticide risks. These strategies included systems for reporting pesticide usage and illness, as well as educational programs about pesticide risks and benefits. In addition, two Institute of Medicine (IOM) committees addressed the general issue of environmental health education, focusing on nurses and physicians, respectively. Both committees recommended an integration of environmental health issues throughout the various stages of training and clinical practice for health care providers. Definition of Environmental Health A common definition of environmental health has been adopted for purposes of this initiative. Environmental health is defined as: freedom from illness or injury related to exposure to toxic agents and other environmental conditions encountered in the home, workplace, and community environments that are potentially detrimental to human health (adapted from the Institute of Medicine s report, Nursing, Health and the Environment (Pope et al, 1995)). Pesticide exposures do occur in workplace settings; therefore, environmental health in the context of this Plan is an overarching category that includes occupational health. Building the Initiative A Collaborative Approach To ensure that collaboration and integration at the federal level could be incorporated at all stages of the initiative, EPA established a Federal Interagency Planning Committee in November 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 brings the expertise of working with a national coalition of health organizations involved in environmental health through its Wellness & The Environment Initiative, and has played a major role in coordinating the initiative with EPA and the federal partners. Several other federal agencies have since joined the initiative and other interested federal partners are welcome to participate. Expert Panel and Workgroups EPA, the Federal Interagency Planning Committee, and NEETF are committed to involving a wider group of key stakeholders through all stages of this initiative, beginning with the development of this Plan. In April 1998, an Expert Panel was convened to identify strategies 3

12 for educating health care providers on how to recognize, diagnose, manage, and prevent adverse health effects from pesticide exposures. This workshop reflected the collaborative nature of this 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 (Summaries of the Expert Panel and workgroup meetings are presented in Appendices A and B, respectively.) Workgroup members, as liaisons to their organizations, have brought important perspectives to this effort and have ensured that their organizations are kept abreast of the initiative. These key stakeholders will play a further role in outreach and consensus building within their organizations and constituencies to move the overall initiative forward. Strategic Outreach Meetings to Build Consensus With the assistance of stakeholders who participated in the Expert Panel and/or the three workgroups, the Federal Interagency Planning Committee will conduct strategic outreach meetings with key professional organizations and decision-making bodies to secure official endorsements. Efforts are currently underway to participate at various national conferences for the purposes of publicizing the Plan and the upcoming national forum, and to begin developing support among stakeholders. Sustained Funding and Support To ensure that sustained funding is available for the implementation and evaluation of both short and long-term components of this initiative, funding and resource support must come from various sources, including federal agencies, professional health organizations, foundations, academia, industry, trade associations, environmental, farm and farmworker and community-based organizations. It is this type of resource sharing and collaboration that will determine the success of this initiative and create a win-win situation of all parties concerned. Summary of the Implementation Plan Objectives The 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 as a model for broader efforts to educate health care providers about the spectrum of health conditions associated with environmental problems. The four main objectives of the Plan are to: Make the case and raise awareness for why primary health care providers should be educated about and trained in ways to address health effects from pesticide exposures. 4

13 Identify the target audience for the initiative and explain how strategies are designed to reach segments of the audience at different stages of their readiness to change. Set forth an agenda to build national consensus on this issue and gain funding and resource support to implement the Plan and evaluate the initiative over a ten-year period from various sources including federal agencies, academia, professional health organizations, foundations, farmworker and farm groups, industry, and trade associations. Articulate a three-pronged strategy and a set of required elements for education settings, practice settings, and necessary resources and tools. Strategic Framework Given that primary care providers are educated and trained in different settings, the Plan specifically 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 school or nursing school. The second prong targets the practice setting in which a provider works and participates in professional development. The final prong articulates the resources and tools that providers need to effectively deal with pesticide-related health conditions in their practices 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 in the health professions are prepared to recognize, manage, and prevent pesticide-related health conditions across the United States. 2. Practice Settings: Change the practice of primary care so that pesticide-related health conditions 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 that take into account existing resources, evaluate their quality and suitability for different audiences, and assure their availability through an informational gateway. For both the educational and practice settings, the Plan recommends a similar set of component projects and activities (see Figure 1). These components serve as a framework for the cohesive implementation of the three-pronged strategy. This Plan intentionally presents the same conceptual framework for both settings so as to ensure consistency in approach. However, the Plan distinguishes between the settings because they often involve different decision-makers and approaches. The components for the settings are: Make the Case for Change Define Guidelines for Educational Competencies or Practice Skills 5

14 Table 1: Components of the Implementation Plan Educational Settings Practice Settings Resources and Tools Component A: Inventory existing resources Determine what educational and informational programs and materials for health care providers currently exist in education and practice settings and what gaps should be filled. Component A: Make the case for practitioners Develop an effective case statement to convince primary care providers about the need to incorporate environmental health and pesticide awareness into their practice settings. Component A: Make the case for change in educational settings Develop an effective case statement to convince decision makers about the need for environmental health and pesticide education in medical and nursing educational institutions. 6 *Component B: Establish a national review board Create a national body to determine assessment criteria and evaluate existing resources, with the goal of identifying, selecting, and assessing the ideal resources that primary health care providers use in both educational and practice settings for prevention, diagnosis, treatment, and referral of pesticide-related health conditions. *Component B: Define practice skills and guidelines Produce 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 into practice and training settings; and provide access to relevant resource materials. *Component B: Define competencies and integration strategies for curricula Produce National Guidelines that recommend competencies specific to the recognition, management and prevention of pesticide exposures, for all basic and advanced training in medicine and nursing; define accompanying content areas; suggest methods of integration into curricula; and provide access to relevant resource materials. *Component C: Create an information gateway Establish a print, telephone, and Web-based gateway through which primary health care providers can access information and educational resources. *Component C: Assess knowledge and skills of practitioners Conduct 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 programs and informational resources. This assessment will be comprised of a literature review, surveys, and focus groups. Component D: Develop teaching/learning resources for educational settings Identify and develop new content resources, tools, and methods for faculty in educational settings. Component D: Secure official endorsements Ensure the integration of the expected practice skills into practice settings by securing the official endorsements of key professional organizations and decision making bodies. *Component C: Assess educational settings Conduct an assessment of the target audience of educational institutions to determine (a) amount of existing coursework, (b) faculty members current knowledge and comfort level with teaching pesticide-related topics, and (c) how faculty and educational institutions will best respond to educational programs and informational resources. This assessment will be comprised of a literature review, surveys, and focus groups. Component E: Develop new resources for practice settings Identify and develop new content resources, tools, and methods for health care providers in practice settings. Component E: Demonstrate model programs Mobilize practice settings to become population-specific and to incorporate environmental considerations (specifically pesticides) into prevention, education, diagnosis, and treatment. Achieve incremental, site-specific improvements in identification, early intervention, and prevention, as well as in measures of practice-specific health outcomes. By 2010, half of all primary health care practice settings in the United States should incorporate environmental considerations in prevention, education, management, and referral. Component D: Secure official endorsements Ensure the integration of the core competencies outlined in the National Guidelines into educational institutions by securing the official endorsements of key professional organizations and decision making bodies. Component E: Strengthen and build faculty champions Create and support faculty champions within medical and nursing schools to teach environmental health and pesticide education in the curriculum, and to bring about change within their institutions. Component F: Create incentives for change Identify and promote a number of incentives to incorporate appropriate prevention, recognition, and management of pesticide-related health conditions into health care practices. Component F: Create teaching incentives Influence the appropriate boards, organizations, and institutions that create board exams to include several key competencies on pesticides and environmental health. * Priority Project

15 Figure 1: Framework of the Implementation Plan Assess Target Audiences in Each Setting Secure Key Endorsements Demonstrate Success Through Faculty Champions and Practice Models Create Incentives for Change. The Plan also outlines a process to develop the resources and tools necessary to ensure the success of the entire initiative: Inventory Resources Establish National Review Board and Conduct Evaluation of Resources Create Internet-based Information Gateway Create New Resources. 7

16 Table 2 provides a listing of the anticipated work products to be produced in this initiative. The projects and products can only be accomplished through partnerships among federal and state agencies, professional health organizations, academia, foundations, industry, farm and farmworker groups, environmental groups and trade associations. EPA and the Federal Interagency Planning Committee encourage interested parties to come forward with their ideas for implementation. Table 2: Initiative Work Products Case Statement for Educational Settings (p. 38) Case Statement for Practice Settings (p. 64) National Pesticide Competency Guidelines for Education (p. 41) National Pesticide Practice Skill Guidelines (p. 67) Report on Knowledge, Attitudes, and Skills of Educators and Practitioners (pp. 49, 71) Organizational Position Papers Endorsing The Plan (pp. 52, 74) Request for Applications/Proposals to Support Faculty Champions (p. 55) Request for Applications/Proposals to Support Practice Models (p. 77) Network of Successful Faculty Champions (p. 56) Network of Successful Practice Models (p. 77) Sample Questions for Educational Examinations (p. 58) New Monetary, Legal, Community-Based, and Peer-Professional Incentives (p. 80) Inventory of Resources (p. 87) National Review Board for Resource Materials (p. 89) Recommended List of Resources (p. 89) Gateway of Resources (print, telephone, Internet) (p. 91) New Resources and Materials (pp. 94, 96) Timeline and Priority Projects A projected timeline identifying the time frame for implementation of the Plan s components is provided in Figure 2. As the timeline shows, several projects have already been initiated, and four component areas will receive priority attention in They are: National Pesticide Competency Guidelines for Education, and National Pesticide Practice Skill Guidelines: These two model documents will recommend competencies for students and practice skills for practitioners to achieve, respectively, the recognition and management of pesticide-related health conditions and exposures. Work on the National Guidelines was initiated in February

17 Figure 2: Projected Timeline for Accomplishing Implementation Plan (based on funding availability) Education: Make the case for change in educational settings Define competencies and integration strategies for curricula* Assess educational settings Secure official endorsements Strengthen and build faculty champions Create teaching incentives Practice: Make the case for change for practitioners Define practice skills and guidelines* Assess knowledge and skill of practitioners Secure official endorsements Demonstrate model programs Create incentives for change Resources: Inventory existing resources Establish national review board Create information gateway Develop teaching/learning resources for educational settings Develop new resources for practice settings Convene National Forum Project Evaluation *Initiated Feb

18 Audience Assessment of Educational Settings and Primary Care Providers: The assessment report will document the knowledge, attitudes and skills of health care provider faculty and practitioners on pesticides and environmental health. Work on the audience assessments will be initiated in Information Gateway: The Gateway will be a print, telephone, and Web-based resource through which primary care providers can easily access information and educational resources in one place about pesticides. This effort will get underway in National Review Board: The National Review Board will determine assessment criteria and evaluate existing resources, with the goal of identifying, selecting, and assessing the ideal resources that primary care providers use in both the educational and practice settings. This effort will get underway in Request for Participation and Public Comment This draft plan is a working document and will be widely shared and disseminated among stakeholders in professional associations, health organizations, educational institutions, government agencies and other groups. The Federal Interagency Planning Committee for this initiative welcomes the widest possible input. The draft Plan will be available for public comment through the Federal Register. Questions about the Plan or initiative can be directed to NEETF at pesticides@neetf.org. Once comments have been reviewed and incorporated, the final Plan is slated to be published in Fall National Forum 2001 The Plan, and progress on implementation of the initiative, will be the subject of a national forum for health care providers scheduled for 2001 in Washington, DC. The national forum will be held over two days with an audience of health care providers and stakeholders, including key decision-makers from various agencies and organizations. The forum will launch this national Implementation Plan, showcasing pesticides as a model for other environmental health issues. Progress on the priority projects initiated this year the National Guidelines, Audience Assessment, Information Gateway, and National Review Board will be featured at the 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 a network of health care providers nationwide; announce an RFP to fund components of the Implementation Plan, and hold training workshops for health care providers. EPA and the Federal Interagency Planning Committee members invite interested organizations and initiatives to participate in the sponsorship, planning, and organization of the national forum. 10

19 Vision, Expected Outcomes, and Evaluation Vision The goal of the Pesticides and National Strategies for Health Care Providers initiative is to improve the recognition, management, and prevention of health effects from pesticide poisonings 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 knowledge of health effects related to pesticide exposures and an ability to take action to ameliorate such effects through clinical and preventive activities. This will be achieved through training and education 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 the following recommendations, adopted from the Institute of Medicine (Pope and Rall, 1995): Environmental health concepts will be reflected in all levels of education of primary care providers, 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. Interdisciplinary approaches will be used when educating primary health care providers so as to draw upon the expertise from various environmental health disciplines. Environmental health content will be an integral part of lifelong learning and continuing education of primary care providers. Professional associations, public agencies and private organizations will provide more resources and educational opportunities to enhance environmental health in primary care practice. Expected Outcomes By 2010, the following expected outcomes of the initiative should have occurred: 1. Professional associations, decision-making bodies, academic institutions, and practice settings have endorsed the need to address health conditions associated with pesticide poisonings and overexposures. 11

20 2. The need for educating health care providers about the health effects of pesticide exposures is an accepted part of primary health care education and practice. 3. Education and practice settings have integrated an endorsed set of educational competencies 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 academic educational institutions, including academic health centers and accompanying nursing schools nationwide. 6. Certification, licensing, and accreditation requirements include attention to the recognition, management, and prevention of health effects related to pesticide poisonings and exposures. 7. Over 100 pilot primary care practices serve as models for effectively integrating attention to 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 organizations to informational resources and educational materials on the issue. 10. Incentives in the health care system have increased the attention that primary care providers pay to the recognition, management, and prevention of health effects from pesticide poisonings and exposures. 11. Resource materials on pesticide poisonings are easily located in the leading sources of information for the health care community (e.g., professional journals, newsletters, central Internet sites, professional meetings). Evaluation of Expected Outcomes This initiative has a long-term perspective and ultimately its success will depend on how well it leads to changes and improved health care in this country. Evaluating its progress along the way and its long-term success will be important, both for making mid-course corrections as needed, and for learning from its achievements and failures. An evaluation team will be contracted to design and implement the evaluation. The evaluation will begin early on in the initiative to ensure that measurement indicators are clearly built into all aspects of implementation. The evaluation will be both formative and summative in nature so as to track both process and outcome measures. The following set of indicators will be used to evaluate the components of the plan. 12

21 Professional Endorsement The major professional associations and organizations involved with the initiative s target audiences endorse and/ or adopt a position paper supporting this Implementation Plan. Professional journals increase the number of peer-reviewed articles and commentaries making the case for recognizing, managing, and preventing health effects from pesticide poisonings and exposures. If you make it relevant to teachers, they ll find a way to teach their students. Marcia Owens, JD Minority Health Professions Foundation Educational Institutions Over 40 percent of educational institutions take steps towards integrating pesticide education into their settings (e.g., adopt components into their curriculum from the National Guidelines, hire a faculty champion, hold Grand Round lectures on the topic, create practice-based internships that address the issue). Over 100 educational institutions have a faculty champion on faculty who integrates a pesticide perspective into the education of health professional students. Certification and licensing requirements include a component related to pesticides, or address the broader understanding of environmental health so that students are tested on at least a portion of the endorsed competencies. Practice Settings Over half of practice settings have taken steps towards building a model practice that addresses health effects related to pesticides (i.e., patient education, history taking, community outreach, use of tools and resources, access to Internet gateway). Model practice settings document improvements based on changes in recognizing, managing, and preventing pesticide exposures. Specific models are tracked in high-impact areas (e.g., migrant farmworker communities, urban settings). Re-certification and continuing education requirements include a component related to pesticides, or address the broader understanding of environmental health so that practitioners are evaluated on at least a portion of endorsed practice skills. Incentives are in place in the health care system to reward health care providers who recognize, manage, and prevent pesticide-related health conditions. 13

22 Utilization of Tools and Resources Tools and resources are being used at an increased rate by health care providers as tracked through sales, requests, downloading off the Internet, and distribution at conferences. An endorsed list of resources is available to health care providers online and through the key dissemination mechanisms. Increased Reporting and Surveillance More health care providers are reporting suspected pesticide poisoning and exposures to state and federal agencies. States with existing surveillance systems have improved outreach to health care providers statewide to report suspected cases. More states implement pesticide surveillance systems with effective outreach and involvement of health care providers. Improvements Recognized by Communities/General Public Community organizations report improved communication and activities by local health care providers and clinics. 14

23 Making the Case Pesticides are ubiquitous in our society. We use them in our homes, workplaces and communities. Due to the widespread dissemination of pesticides, and the potential for related illness and injury (especially among farmworkers and pesticide handlers), primary care providers should be prepared to recognize, manage, and prevent pesticide-related health conditions with their patients and communities. When pesticide toxicity is discussed, most people usually think of an acute pesticide poisoning incident in an agricultural setting. However, pesticides are also of concern because of potential chronic health effects from long-term exposures. In addition, pesticide exposure can occur in a number of settings outside agriculture, including urban environments, homes, and schools. For these reasons, patients and communities often look to their primary care providers as important sources of information and guidance on suspected pesticide-related health conditions. 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 in identifying and ameliorating potential pesticide poisonings and exposure. However, more needs to be done to ensure that health professionals are prepared for this role and that they know 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, provide timely treatment for pesticide-related illnesses, provide prevention education, and, where appropriate, consult with local authorities. This Plan offers a way for health care professionals to be effectively prepared through their education and training, and to maintain this knowledge while in practice. This Plan is based on the premise that addressing pesticide-related health conditions can be a part 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 competing public 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 practitioner can use when the need arises. Primary care providers working with high risk populations may need 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 efforts should involve primary care providers. Research should focus on what conditions primary care providers see in their practices, specifically with regard to chronic exposures. As this 15

24 initiative evolves, it is recommended that epidemiologic research be developed using a registry of primary care offices to identify conditions requiring further research and documentation. Following are a number of reasons, accompanied by supporting data, why pesticide-related health conditions are relevant to the practice of primary care today: Patient and Community Concerns Recent Public Pesticide Issues Potential for Acute Exposures and Effects Potential for Chronic Exposures and Effects Clinical Case Examples Current Provider Training and Education in Environmental Health Patient and Community Concerns Primary care providers are on the front lines of providing health care. Patients and communities often ask for advice about a suspected pesticide exposure or ask the provider to investigate a potential health condition to see if it might be related to pesticides. Public concern about pesticides has been documented and often shows up in the questions asked by patients of their personal primary care providers. By helping patients problem solve and evaluate risks from pesticides, primary care providers can help patients reduce risk to exposure and prevent future exposures. In addition, an alert clinician will also be able to identify a potential exposure when 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 country and a million or more pesticide applicators who are often at greater risk for pesticide exposure because of mixing or applying pesticides or working in fields where pesticides are applied. A provider community that is more aware of the specific concerns of this population will be better 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 a list of 30 potentially hazardous activities, use of pesticides was perceived to rank in the top 10 most risky activities, higher in riskiness than surgery, electric power, swimming, large construction, x-rays, or bicycles (Slovic et al, 1980). Health care providers have an important role in helping their patients evaluate the relative risks from different types of environmental exposures, including pesticides. Health care providers need to be able to counsel patients about realistic risks, and avoid unwarranted trivialization or exaggeration of the risks. 16

25 FREQUENTLY ASKED QUESTIONS OF PRIMARY CARE PROVIDERS Providers are often asked basic questions by their patients. Here is a sampling of pesticide-related questions and concerns that patients bring to their visits with providers: (1) I received a report from my water utility that said the water contains 0.5 ppb of dibromochloropropane. What is this chemical, what does it mean for my health, and what should I do? (2) I just read in the newspaper that schools in my state are spraying their buildings with toxic pesticides. I m worried because my child has asthma and 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 the exterminator in to flea-bomb the house? The exterminator says it s safe if we 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 and he 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 it may be because the janitor sprays pesticides at night. (6) I am a farmworker and was picking celery in the fields. Today I have a rash on my hands and arms. Is it from the chemicals? In large measure, this initiative is intended to help prepare the primary care provider with the information, skills, and resources to begin problem solving with patients. The questions in the 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 patients evaluate the risks and determine whether further steps are required. Recent Public Pesticide Issues Misuse of Pesticides Methyl Parathion Case Studies of Misdiagnosis Under the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA), EPA regulates an organophosphate insecticide called methyl parathion for use on specific crops. In the 1980s and 1990s, methyl parathion was widely used illegally in indoor environments by unlicensed applicators. One published report describes methyl parathion-related illness among seven siblings, two of whom had a fatal outcome (CDC, 1984). Approximately two days before these children were correctly diagnosed, five of them were seen by their local physician and sent back to their contaminated home with a mistaken diagnosis of viral gastroenteritis. Since 1984, at least five different states have reported illegal use of methyl parathion inside homes 17

26 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 and businesses. Some people exposed to methyl parathion in their homes experienced mild symptoms of organophosphate poisoning (e.g., nausea, headache, difficulty breathing, blurred vision) and some of them complained to their health care professionals. A report summarizing the 1995 investigations in Ohio (where at least 500 homes were treated illegally) found that 20% or more of respondents reported symptoms during the two weeks following methyl parathion application (NCEH, 1996). Unfortunately, corrective action was not enacted until More than 1,500 individuals were relocated from their home. The estimated clean-up cost for these incidents is more than $90 million (Environews, 1997). Misdiagnosis of organophosphate poisoning can be a severe problem. Zweiner and Ginsburg (1988) reviewed a case series of 37 infants and children poisoned by organophosphates and carbamates. Of 20 cases transferred to Children s Medical Center in Dallas, 16 (80%) had an incorrect transfer diagnosis ranging form encephalopathy and seizure disorder to pneumonia and pertussis. Each of these cases of misdiagnosis or delayed diagnosis demonstrates the potential for acute exposures, public concern, and expenses related to the widespread use (and often misuse) of pesticides in our country. The primary care provider can play a vital role in helping individuals deal with these exposures. Furthermore, alert providers aware of potential health conditions related to pesticide exposure can become a key link in limiting the spread of pesticide epidemics by identifying sentinel cases and bringing them to the attention of appropriate public health officials responsible for pesticide-related illness surveillance. Control of Exotic Pests Increase in Potential Pesticide Exposures to the Public A growing number of exotic and public health pests are besieging the United States. Control of these pests increases the potential for pesticide exposure to large segments of the public. Aerial application of insecticides over residential neighborhoods involving millions of people has recently been conducted in New Jersey for control of malaria-carrying mosquitoes, in New York City for control of mosquitoes carrying the West Nile virus, and in several Florida counties for control of the Mediterranean fruit fly (Medfly). Surveillance conducted during 18

27 the recent Florida Medfly Eradication Program identified 123 individuals with illness potentially related to pesticides used in the program (CDC, 1999b). During pesticide spraying campaigns to control exotic pests, health care providers are often called upon to provide sound preventive advice, and to recognize and manage any pesticide-associated illnesses. Careful documentation and reporting of suspected cases are needed to protect those who may be unusually susceptible to low-level exposures. Potential for Acute Exposures and Effects Health care providers may be faced with patients who have experienced acute pesticide poisonings. A pesticide poisoning is considered acute when the onset of symptoms occur shortly after the time of pesticide exposure. Acute pesticide poisonings can differ in their degree of severity. While providers may not see very many acutely poisoned patients, they should possess a basic understanding of signs and symptoms, and an ability to diagnose and refer. Oftentimes it is the primary care provider who identifies possible sentinel cases that signify the presence of previously unrecognized pesticide hazards in the community. By notifying the proper authorities of real or potential poisonings, health care providers can play a critical role in pesticide-related illness surveillance. Agricultural Exposures Agriculture accounts for 76 percent of the conventional pesticides used annually (approximately 944 million pounds, not including disinfectants, wood preservatives, or water treatment chemicals) (U.S. EPA, 1999). Pesticide handlers and agricultural workers appear to be at greatest risk for acute pesticide poisoning. Based on states with required reporting of pesticide-related health concerns, EPA estimates there are approximately physician-diagnosed cases occur per 100,000 agricultural workers (including pesticide handlers) (Blondell, 1997). Migrant and seasonal farmworkers are especially at high risk since they often work and live in poor occupational environments where pesticide exposures can be significant. Non-Agricultural Exposures Urban and suburban uses of pesticides can be as high as in some agricultural areas. A 1990 EPA survey estimated that 84% of American households used pesticides, most commonly insecticides (Whitmore et al, 1992). Homeowners annually use 5-10 pounds of pesticide per acre on their lawns and gardens, many times the amount applied by farmers to corn and soybean fields (Robinson et al, 1994). They also use pesticides in the form of disinfectants, including pine oil cleaners, bathroom cleaning products, and cleaning materials for swimming pools. In addition, work-related exposures for structural pest control operators and workers in nurseries, greenhouses, and landscaping are also of concern in the nonagricultural sector. 19

28 A substantial number of people in the US are at risk of acute pesticide poisoning from nonagricultural uses. One of the major sources of data on acute pesticide poisoning is the Toxic Exposure Surveillance System (TESS) maintained by the American Association of Poison Control 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 to their local poison control center. All 40,000 calls were from individuals who had a concern about overexposure, not requests for information. It is estimated that as many as 60% of these individuals developed symptoms of pesticide poisoning. These figures are thought to represent 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 centers were notified about approximately 80,000 children (age 0-19) being exposed to common household pesticides in the United States. It is estimated that one quarter of those children developed symptoms of pesticide poisoning. In a study of unintentional exposures to pesticides (excluding disinfectants), EPA found that 78,500 such exposures were reported annually to poison control centers in , 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 control centers) 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 Pyrethrins and pyrethroids** Pine oil disinfectants Hypochlorite disinfectants Insect repellents Phenol disinfectants Carbamate insecticides Organochlorine insecticides Phenoxy herbicides Anticoagulant rodenticides All other pesticides , Total all pesticides/ disinfectants ,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,

29 outcome (Litovitz et al, 1997). In , there were an estimated 24,000 emergency department visits annually resulting from pesticide exposure, of which 61% of the cases involved children younger than 5 (McCaig, 2000; McCaig and Burt, 1999). These figures are likely under-estimates and may represent only a fraction of the incident cases of acute pesticiderelated illness among children. Pesticides Most Often Associated with Pesticide-Related Health Conditions Organophosphate and pyrethroid insecticides are the categories of pesticides most often implicated in acute pesticide-related illnesses reported to poison control centers. Table 3 on the previous page ranks the class of pesticides most often linked to symptoms in patients, based on data from TESS. This table includes only unintentional exposures to single pesticide products. Potential for Chronic Exposures and Effects Patients and others in the community may also come to providers with concerns about the chronic health effects of both short and long-term exposure to pesticides. While current scientific evidence does not offer definitive conclusions about the health effects associated with chronic exposures to pesticides, early scientific findings lend support to the hypothesis that overexposures or significant exposures to some pesticides may be associated with the onset of cancer, neurodevelopmental effects, and reproductive effects. A well-informed health care provider who possesses a basic understanding of the latest scientific evidence is better prepared to talk with and counsel patients who are understandably concerned about pesticide exposures and uncertain about the risk of future adverse health effects. Risk communication is a critical aspect of the therapeutic encounter, and requires active listening 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 of knowledge about long-term outcomes. Clinicians face the daunting challenge of providing appropriate reassurance where needed, while being careful not to dismiss a patient s concerns without investigating them. Under certain circumstances, the most effective course of action may be to refer the patient to an occupational/environmental specialist, and the list of resources for that referral should be readily available in every clinical practice. On the other hand, the primary care clinician may wish to provide this information directly, and information sources are available to help. Cancer Studies With regard to the relationship between chronic pesticide exposure and cancer, EPA has received and reviewed the required studies for predicting cancer effects for numerous active ingredients. Over 60 of these active ingredients have been classified as probable human carcinogens by EPA or the International Agency for Research on Cancer ( pesticides/carlist/table.htm). Although most of these pesticides are no longer on the market 21

30 or have had their uses severely restricted, their potential to cause cancer in persons previously exposed is still a concern. A review by the National Cancer Institute (NCI) lists 15 pesticides for which there is evidence of cancer in human epidemiologic studies (Zahm et al, 1997). A large prospective study of commercial pesticide applicators and their spouses is underway in Iowa and North Carolina, funded jointly by the National Cancer Institute and EPA, to try to determine 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 also associated with farming (Hoar et al, 1986; Wigle et al, 1990; Zahm et al, 1990). Concerns have also been raised about the relationship between organochlorine compounds and breast cancer and 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 Effects Many insecticides and fumigants are designed specifically to target the nervous system of the pest they are intended to control (referred to as neurotoxins). There is increasing human evidence in the form of case reports and epidemiologic studies that suggests that humans may experience chronic neurologic or neurobehavioral effects following high levels of exposure to certain types of pesticides (Keifer and Mahurin, 1997). Several reports have also found chronic neurological sequelae (reduced neurobehavioral function) after acute organophosphate (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 subjects probably experience persistent neurobehavioral effects as a result of their exposure. In November 1999, the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (1999) of the Department of Health in the United Kingdom concluded: The balance of evidence supports the view that neuropsychological abnormalities can occur as a long-term complication of acute OP poisoning, particularly if the poisoning is severe. Such abnormalities have been most evident in neuropsychological tests involving sustained attention and speeded flexible cognitive processing ( mental agility ). Studies on Reproductive Effects Many pesticides have been identified as developmental or reproductive toxicants based on animal studies. There is increasing evidence for reproductive effects associated with exposure of males to occupational agents. Some of the best known examples are reductions in fertility and sperm counts in men who were occupationally exposed to dibromochloropropane (Sever et al, 1997). Dibromochloropropane (DBCP), a nematocide that was banned by EPA in 1979, produced azo-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 both maternal and paternal pesticide exposures. Areas of particular concern include infertility and time to pregnancy, spontaneous abortion, neural tube defects, and limb reduction defects. 22

31 Studies on Other Health Effects/Specific Populations Hypotheses related to pesticide effects on respiratory, cardiovascular, endocrine, and other body systems have also been suggested and are currently being studied. The impact of pesticides on child development is also a growing area of research and investigation. While studies have indicated associations between pesticide exposures and chronic health effects, there still remains insufficient evidence to document a causal relationship between frequently used pesticides and long term health effects, except in a few cases such as arsenicassociated cancer, male infertility due to exposure to dibromochloropropane, and neurologic sequelae following severe poisonings with neurotoxic pesticides. Studies that suggest associations between pesticide exposures and long-term health effects require support from studies with stronger research designs before causal relationships can be accepted. Health care providers must be taught how to interpret the current state of knowledge in order to assist 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 exposures represents a special challenge to health care providers. The nature of scientific inquiry yields associations between pesticide exposures and health effects long before causal relationships can be reasonably concluded. These associations and the publicity they generate can be enough to raise concerns among patients and the community. Providers should be sensitive to the level of concern and the need to provide reassurance, as well as the possibility that a referral to an occupational and environmental medicine specialist may be indicated. Evaluation of patient concerns about toxic exposures can be complicated by time constraints and the need to engage in non-clinical efforts. For example, site visits and industrial hygiene consultations 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 how to obtain an appropriate referral. Clinical Case Examples: The Challenge of Diagnosing Pesticide Exposures For many pesticides, the short-term and many of the long-term health effects associated with exposure can easily be mistaken for other agents or health conditions. The ability to recognize a 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 the settings that predispose patients to pesticide exposure, the symptoms associated with these exposures, and appropriate diagnostic methods. Case Study 1 Chronic Health Conditions At the Environmental and Occupational Health Sciences Institute (EOHSI) at the University of Medicine and Dentistry of New Jersey, two farmers were referred to the occupational medicine clinic for problems associated with the use of pesticides. Initially, the concern was 23

32 the possibility of drug interaction and pesticide use. Both farmers had worked in a large lima bean operation, and extensively used organophosphate compounds from early in the season until the harvest. The initial evaluation, along with an industrial hygenist s evaluation of the farm, led the health scientists and physicians to conclude that both men were chronically exposed to a series of OP compounds. A careful and rigorous evaluation of all activities led to putting in place the use of personal protective equipment, installation of an on-site shower for 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 symptoms of blurred vision, lack of concentration, headaches, etc. A coordinated effort of the Cooperative Extension faculty, as well as the clinical faculty at EOHSI, led to the diagnosis and a very positive outcome. An earlier evaluation by the local physician did not connect pesticide exposure to the health problems; in fact, the farmers were told 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 to the Extension Service and then to the specialists at the university. Case Study 2 Aldicarb Exposure The following case study, reported in the Morbidity and Mortality Weekly Report (CDC, 1999a), describes a foodborne outbreak of aldicarb poisoning that occurred when improperly stored 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 hospital infection-control nurse reported the incident to the Louisiana Office of Public Health, which then 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 persons who ate the cabbage salad, 14 became ill (attack rate: 88%); the four persons who had not eaten the cabbage salad did not develop symptoms. The employee who prepared the cabbage salad reported mixing precut, prepackaged cabbage in 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 company lunch. The contents of the black pepper container were tested for organophosphate and carbamate pesticides. Testing showed the granules in the pepper container as 13.7% aldicarb. A 6-gram portion of cabbage salad contained parts per million of aldicarb, a level which can produce illness in humans. The deceased owner of the pepper can had been a crawfish farmer, and it is believed that he used aldicarb on bait to prevent destruction of his crawfish nets, ponds, and levees by wild dogs and raccoons. 24

33 Cholinesterase-inhibiting pesticides (i.e., organic phosphates and carbamates), which are widely 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 public health officials should keep in mind that food poisoning might result from pesticide or other chemical contamination as well as from infectious organisms. Case Study 3 Organophosphate Exposure A couple in their sixties entered their vacation condominium in Hawaii and were immediately aware of a strong odor. Three days later they discovered that the odor emanated from a leaking five-gallon can of liquid Metasystox-R-2, an organophosphate insecticide which was being stored in a room adjoining the condominium. The chemical container had leaked and saturated the 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 of continuing and increasingly severe headaches, blurred vision, and shortness of breath (i.e., symptoms compatible with organophosphate intoxication). Pulmonary function tests were performed and unexpectedly revealed mild obstructive pulmonary disease with the test improving following use of a bronchodilator. No other testing was performed. The physician treated the couple for a mild reactive airway disease and told them to return for further care only if symptoms persisted. When they inquired about the need to investigate continuing or residual effects from exposure to the pesticide, the physician did not know how to answer. When symptoms persisted, the couple called the National Pesticide Telecommunication Network (NTPN) and were advised to return immediately to the physician and request a cholinesterase enzyme assay analysis. The results for the male were minimally above the lower normal range (i.e., consistent with either an acute or resolving intoxication). NPTN advised the couple to vacate the condominium and contact the Hawaii Department of Agriculture, which helped identify a commercial laboratory that confirmed the contamination, and provided clean up. The couple s symptoms resolved approximately two weeks later. Case Study 4 Arsenic Exposures A clinician examined a rural family of eight with a number of signs and symptoms. Family members had conjunctivitis, bronchitis, pneumonia, sensory hyperthesia of the arms and legs, muscle cramps, dermatitis over the arms, legs and soles of the feet, nosebleeds, ear infections, blackouts and seizures, gastrointestinal disturbances, and severe alopecia. Symptoms became 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 even child abuse. Only when a toxicologist heard about the case from the news media and performed appropriate laboratory tests on environmental samples was the source of the problem identified, three years later. The problem was found to be burning arsenic-copper-chromated treated wood (outdoor grade plywood) in the family s wood stove. 25

34 These case studies point to the preventable human suffering and death that can be associated with delayed or missed diagnoses of pesticide poisoning. Since the use and presence of pesticides are so ubiquitous in our society, there is a strong argument for sensitizing all primary care physicians to develop a high index of suspicion and diagnostic acumen, including consultation when needed, to respond promptly to patients whose presentations may represent pesticide poisoning. While it is anticipated that providers working with high-risk populations such as in agricultural areas, emergency departments, and pediatrics will be most sensitive to this proposition, these cases show the potential for such severe health consequences that all primary care providers are advised to be vigilant. Current Provider Training and Education in Environmental Health Health care providers are the primary audience for this Plan because the public looks to them for guidance on health concerns. While some progress has been made in introducing environmental health issues into curricula at medical and nursing schools, most health providers still do not have adequate knowledge and tools to address patient and community concerns. Key studies by recognized medical institutions and committees convened by federal agencies and national scientific bodies have addressed this concern: In 1985, only 50% of medical schools addressed occupational and environmental health in their 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 occupational and environmental health over four years (Schenk et al, 1996). (See box on next page). In 1988, an Institute of Medicine (IOM) committee on the role of the primary care physician in occupational and environmental medicine recommended that all primary care physicians be able to identify possible occupational or environmentally induced conditions and make appropriate referrals (IOM, 1988). In December 1994, the American Medical Association adopted a resolution urging Congress, government agencies, and private organizations to support improved strategies for the assessment and prevention of pesticide risks (AMA, 1994). Specific recommendations to change medical/nursing education and practice were made by two IOM committees on medicine and nursing, in 1994 and 1995, respectively. In 1995, the Institute of Medicine produced two landmark reports Environmental Medicine: Integrating a Missing Element into Medical Education and Nursing, Health and the Environment that called for more effective environmental health education and training of medical and nursing professionals. Health care providers can be extremely effective in addressing pesticide exposures in the lives of their patients and in their communities. However, they do not need to become experts in order to fill an important and crucial role. Some of the important knowledge and skills that they should possess include: 26

35 TRAINING OF PRIMARY CARE PROVIDERS A 1994 survey of environmental medicine content in U.S. medical schools found that: Ninety US medical schools (76%) reported requiring environmental medicine content in the curriculum. Only two schools (2%) had a dedicated course. Eighty-nine schools (75%) indicated that environmental medicine was taught as part of a required course. Forty-six schools (39%) offered it as an elective course. Fifty schools (42%) reported no instruction in taking an exposure history. Among schools with required environmental medicine instruction, the average time in the curriculum was seven hours over the four years of medical education. An average of three hours of environmental medicine instruction was provided in preclinical courses and four hours in clinical courses. Eighty-one schools (68%) reported some faculty with environmental and occupational medicine expertise, most often in departments of internal medicine (42%), community/preventive medicine or public health (37%), and family medicine (28%). Nineteen schools indicated innovative or unusual approaches to teaching environmental medicine, including small group case discussions, communitybased clerkships, and site visits. These schools reported an average of five faculty members with occupational/environmental medicine expertise, compared with an average of four faculty members for all other schools. Note: Of the 126 schools surveyed, 119 (94%) responded. Source: Schenk et al, Recognizing possible signs and symptoms of pesticide exposure Taking a brief and relevant environmental and occupational history Diagnosing possible associated health conditions, including those of sensitive populations such as children and the elderly Calling upon an appropriate specialist or expert to assist them Having ready access to a recommended referral list of resources and contacts Providing basic preventive guidance for patients Recognizing when to report exposure incidents to the proper health authorities Possessing a basic awareness of environments in which patients live, work, and play Identifying possible sentinel cases Participating in surveillance systems. 27

36 This initiative emphasizes the provider s ability to recognize a potential pesticide exposure, to communicate effectively, and to access and work with pesticide/environmental health experts and resources. In an educational setting, this may mean working with an occupational and environmental medicine specialist to design and integrate a pesticides module into a toxicology course for medical students. In a practice setting, this may involve incorporating an environmental history into primary care practice and referring patients to appropriate experts in 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 pesticide topics could be inserted into the curriculum. Clearly, the issue of pesticide-related health conditions is one that requires the participation of health care providers. The rationale given in this section serves as the underpinning of the three-pronged strategy in this Plan. 28

37 Target Audience For the purpose of this initiative, the target audience is the primary care provider. Primary care providers work at the front lines of our health care system and therefore need to be able 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. A primary care provider, for the purpose of this initiative, is defined as: a physician, nurse, nurse practitioner, physician assistant, nurse midwife, or community health 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 for purposes of this initiative and for primary providers. However, because they already have a higher awareness of pesticide issues, specialists in occupational and environmental medicine are not the primary target of this initiative. They are seen as resource professionals for the primary care 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. In addition to these primary care providers, the target audience also includes key decision-making bodies in the health profession. A decision-making body, for purposes of this Plan, refers to any 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 emergency departments community clinics medical centers independent practices industry, workplaces alternative points of care public health departments poison control centers schools 29

38 organization, institution, or individual leader that is vested with decision-making authority for the education and practice of health care in the United States. This includes, but is not limited to, curriculum committees, residency review committees, exam development bodies, accrediting institutions, organizations representing academic institutions, faculty, and administrators, and institutions governing health care practice and requirements. The engagement of, and endorsement by, such bodies is the only way to ensure success of this Plan and the larger initiative. Understanding the Target Audience Consulting the available literature on how health professionals learn is an important first step in determining the most effective approaches to use. One of the models explored in the development of this Plan is the Stages of Change model (Prochaska et al, 1995) that looks at behavior 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 change requires different types of interventions and resources. The model outlines a continuum of behavior change that can be used to help understand where the target audience is on the continuum, and to effectively reach the audience (through targeted messages, strategies, and programs) 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 for has not thought through behavior change, personalize information and risks and benefits Contemplation Thinking about change in the Motivate, encourage to make near future specific plans Decision/Determination Making a plan to change Assist in developing concrete action plans, setting gradual goals Action Implementation of Assist with feedback, problem specific action plans solving, social support, reinforcement Maintenance Continuation of desirable Assist in coping, reminders, actions, or repeating periodic finding alternatives, avoiding recommended step(s) steps/relapses (as applies) Source: Prochaska et al, Applying the stages of change model to the current initiative, the concepts can be consolidated into three categories or stages of change: Stage 1: Building awareness and motivation At this stage, the goal is to increase awareness and motivation by making an effective case, and increasing the motivation to change. 30

39 Stage 2: Readiness to make changes To turn readiness into actual change, the goal at this stage should be to build on knowledge and skills, for example, by creating new resources and disseminating them effectively. Stage 3: Maintenance, champions For those who have already made a change, the goal is to maintain support for the change activity and nurture champions who will advocate for change. When it comes to understanding and dealing with pesticide-related health conditions, many primary care providers may currently fall in the first category (Stage 1), particularly those working in urban areas. Nevertheless, resources should still be created and made available for all three categories, 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 change in the target audience. Figure 3: Stages of Change and Implementation Plan Components STAGE 1: Awareness and Motivation-Building Make the Case Create Incentives Secure Endorsements New Resources STAGE 2: Knowledge and Skill Building Define Competencies Models of Change Faculty Champions Information Gateway New Resources STAGE 3: Maintenance and Champion-Building Faculty Champions Information Gateway New Resources 31

40

41 Framework of the Plan: A Three-Pronged Strategy This Implementation Plan sets forth a three-pronged strategy to reach the goal of improving the recognition, management and prevention of health effects from pesticide poisoning and exposure. Given that primary care providers are educated and trained in different settings, the Plan sets out 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 second prong targets the practice setting in which a provider works and participates in professional development. The final prong articulates the resources and tools that providers need to effectively 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 in the health professions are prepared to recognize, manage, and prevent pesticide poisoning and exposures across the United States. 2. Practice Settings: Change the practice of primary care so that pesticide-related health conditions 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 that take into account existing resources, evaluate their quality and suitability for different audiences, and assure their availability through an information gateway. For each setting, the Plan recommends a set of components. These components serve as a framework for the cohesive implementation of the three-pronged strategy. In some cases, the components 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 ensure consistency in approach. However, the Plan distinguishes between the settings because they often involve different decision-makers and approaches. The components for each setting are: Make the Case for Change Define Guidelines for Educational Competencies or Practice Skills 33

42 Assess Target Audiences in Each Setting Secure Key Endorsements Demonstrate Success Through Faculty Champions and Practice Models Create Incentives for Change. The Plan also outlines a process to develop the resources and tools necessary to ensure the success of the entire initiative: Inventory Resources Establish National Review Board and Conduct Evaluation of Resources Create Internet-based Information Gateway Create New Resources. 34

43 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, academic health centers, training programs for all levels of nursing education, and medical residency programs. While the components target the educational setting, they also involve the professional associations and decision-making bodies that represent and/or influence the educational 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 following components cut across the continuum of systemic change from raising awareness and assessment, to development of core competencies, to the support of faculty champions and model programs. EDUCATION Component A: Make the case for change in educational settings Develop an effective case statement to convince decision-makers about the need for environmental health and pesticide education in medical and nursing educational institutions. Component B: Define competencies and integration strategies for curricula Produce National Guidelines that recommend competencies specific to the recognition, management and prevention of pesticide exposures, for all basic and advanced training in medicine and nursing; 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 audience of educational institutions to determine (a) amount of existing coursework, (b) faculty members current knowledge and comfort level with teaching pesticide-related topics, and (c) how faculty and educational institutions 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 core competencies outlined in the National Guidelines into educational institutions by securing the official endorsements of key professional organizations and decision-making bodies. 35

44 EDUCATION Component E: Strengthen and build faculty champions Create and support faculty champions within medical and nursing schools to teach environmental health and pesticide education 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 pesticides and environmental health. 36

45 EDUCATION COMPONENT A: Make the Case for Change in Educational Settings EDUCATION Statement Develop an effective case statement to convince administrators, faculty, and students about the need for environmental health and pesticide education in medical and nursing education. Expected Outcomes A written case statement that documents the key reasons why faculty members and administrators of academic institutions should be aware of pesticide-related health conditions, using persuasive data and documentation of the scientific literature, and stressing the importance of teaching pesticides content in their educational curriculum. Endorsement by leading national professional associations, national bodies, deans, and faculty committees. Target Audience Awareness and Motivation: This component is targeted at educational institutions and key strategic organizations that need to be convinced that the issue of pesticides and the need to educate health care providers about this issue are relevant to the educational settings of health care providers. Proposed Activities Activity #1 Research and develop a case statement, solicit peer review, and finalize with the input of key stakeholder groups in the field. The target audiences for the case statement are educational settings and the organizations that work with them. Points to be covered in the case statement: Specific importance of environmental health education and the breadth of the problem of pesticide-related health conditions. Convincing arguments for why pesticides should be in the curriculum, with cited scientific data, along with relevance to faculty and students. 37

46 EDUCATION Compelling arguments to gain the attention of health care students and faculty despite the fact that their time and attention are in high demand elsewhere. Emphasis that faculty do not need to become experts, and reassurance that experts exist in the field who can work with them on coursework and teaching. Emphasis on practical learning for students in settings where pesticide exposures may occur. Reassurance that user-friendly teaching materials are available for faculty to use, along with user-friendly guides, and curriculum maps indicating where pesticide topics could be inserted into the curriculum. Recommended amount of time to dedicate to pesticides in the curriculum that is reasonable given the other demands on academic institutions. Activity #2 Promote the case statement through effective dissemination mechanisms to administrators, faculty, and curriculum committees, including print and Internet information sources. Activity #3 Publish journal or newsletter articles on making the case for the academic setting in professional journals and publications. Activity #4 Hold strategic meetings with bodies that accredit health educational institutions and set curricular requirements, and with national leaders to seek their endorsement of the case statement. This includes identifying a subset of decision-makers who can be influenced by the case statement. Stakeholders Professional associations Key accrediting bodies Curriculum committees Deans/Department chairs Evaluation of Outcomes/Indicators of Success Complete case statement. Published articles in professional journals and newsletters. Position papers developed and adopted by professional associations. 38

47 Background This component was crafted based on the recognition that we need to raise awareness about why educating health care providers about pesticide-related health conditions and exposures is so 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 together in 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 entire field in making the case for the education of health care providers on this topic. The case statement will complement a similar statement to be created for practice settings. EDUCATION 39

48 EDUCATION EDUCATION COMPONENT B: Define Competencies and Integration Strategies for Curricula Statement Produce National Guidelines that recommend competencies specific to the recognition, management and prevention of pesticide exposures, for all basic and advanced training in medicine and nursing; define accompanying content areas; suggest methods of integration into curricula; and provide access to relevant resource materials. Expected Outcomes National Pesticide Competency Guidelines for Education which recommend competencies, content, insertion points into curricula, and resources. The Guidelines will be completed in mid Endorsement of National Guidelines by leading national professional associations. Target Audience Readiness to Change: This component is targeted at administrators and faculty in educational institutions. The guidelines are to assist faculty in integrating the recommended core competencies into curricula. This component assumes that administrators and faculty members have been convinced that this is an important topic for their curricula and that they are ready to change their curricula. Proposed Activities Activity #1 Define the core competencies for educational institutions to teach about pesticides in basic and 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 Workgroup in 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. 40

49 Activity #2 Produce National Pesticide Competency Guidelines for Education to educate students about the recognition and management of pesticide-related health conditions and exposures. A complementary document will focus on the practice settings in which primary care providers work. An accompaniment to the Recognition and Management of Pesticide Poisonings handbook, the National Guidelines will be designed as a userfriendly guide on how to integrate pesticides content into curricula. The Guidelines will be drafted by a team of experts and will contain the following components: Recommended competencies. Relevant content for each competency area. Suggested points of insertion into curricula (expected to vary between medical and nursing schools as well as for basic or advanced training). 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 nursing and 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 (both for traditional educational programs and problem-based learning programs), for medicine and nursing. Develop a curriculum map i.e., an outline of what courses are taught during 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 that can be added to a computerized database of curricular content. 5) Develop recommendations for designing and implementing teaching/learning strategies with course directors, faculty (including deans), and students. 6) Develop strategies/methods to evaluate student competencies. I see us planting seeds at various levels... Matthew Keifer, MD, MPH University of Washington 7) Participate in coordination of content development and windows of opportunity between medicine and nursing in a timely fashion. 41

50 EDUCATION 8) Coordinate with the team designing the complementary practice document. The National Guidelines will not contain actual teaching modules or resources, but rather provide a 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 set up for reviewers to comment on and make proposed changes to the National Guidelines. Activity #3 Promote the National Guidelines with key stakeholders. Solicit official endorsements and organizational support of report, including dissemination to their members. Stakeholders Academic institutions National professional associations for academic institutions Faculty members who have already developed curricula Evaluation of Outcomes/Indicators of Success National Guidelines completed and peer reviewed by at least 10 key individuals and organizations. Endorsement by key stakeholder organizations. Background In defining competencies in pesticides and environmental health, several key recommendations have helped to frame this component. Build upon existing documents: The competencies must relate to the Institute of Medicine competencies for medical and nursing education, so that no duplication of effort occurs. Balance between pesticides and environmental health: One of the most difficult questions is the relative balance between environmental health topics in general and pesticides in particular. Having the competencies deal specifically with pesticides avoids any charges of duplication, and might even be seen as a useful model for developing other competencies in specific areas. Focus on basic and advanced levels: Although Table 6 presents competencies for three levels of learning (basic, advanced, specialty), the focus of the initiative will be on basic and advanced, which are most relevant for training primary care providers. Other 42

51 organizations, including the American College of Occupational and Environmental Medicine, American College of Medical Toxicology, and the American Association of Occupational Health Nurses, are focusing on specialty training. Categorize the competencies: The six categories of competencies shown in Table 6 were derived from a combination of the Institute of Medicine s medicine and nursing recommendations. They are meant to apply to medical, nursing, and allied health school curricula. The six categories are: EDUCATION Basic Knowledge and Concepts of Pesticides Diagnosis/Assessment Treatment/Intervention/Referrals/Follow-up Risk Communication, Advocacy, and Ethics Reporting Legislative and Regulatory Knowledge. 43

52 Table 6: Proposed Competencies for Educational Institutions Competency I: Basic Knowledge and Concepts of Pesticides Basic: 4-year medical school, undergraduate nursing, undergraduate allied health professional education 1. Principles of Environmental and Occupational Health 1a. Understand principles of environmental and occupational health 1b. Understand broad spectrum of chemicals classified as pesticides and areas of use (should be aware of various types of pesticides) 1c. Understand mechanisms and pathways of exposure 2. Individual and Patient Knowledge and Skills 2a. Be aware of the environment in which the patient (and family) lives, works, and plays (understanding of the hazards and potential exposures in different settings) 2b. Identify risk factors for pesticide exposure (e.g., occupation, location of home, vulnerable populations) 2c. Recognize that other family members may be ill as well (Possibly due to exposure in the home) 2d. Recognize socio-economic impacts on the patient of pesticide-related illness 2e. Understand potential moral, ethical and legal implications for patients of reporting and referral 3. Population-Based Health Knowledge and Skills 3a. Understand population-based health, including epidemiology 3b. Recognize socio-economic impacts of pesticiderelated illness 3c. Understand potential moral, ethical and legal implications for the community of reporting and referral 3d. Possess a basic awareness of the role of prevention, general awareness of benefits of alternatives to conventional pest control Advanced: Medical residents, advanced practice nursing students, physician assistant students, other advanced degree programs (Faculty in primary care would need to be at this level to teach) 1a. Strengthen skills from Basic competencies 1b. Understand temporal relationship between exposure and symptoms (Medicine) 1c. Understand advanced toxicology, specifically related to organophosphates, carbamates, and pyrethroids (most commonly reported pesticides implicated in symptomatic illness) 2a. Strengthen skills from Basic competencies 2b. Understand at a basic level the health effects of organophosphates and carbamates 2c. Identify risks to patients served (i.e., special vulnerabilities of children, the elderly) 3a. Strengthen skills from Basic competencies 3b. Develop more in-depth knowledge of the environment in which they are learning and practicing 3c. Develop specific understanding of communities and populations at risk for pesticide exposure 3d. Understand advanced epidemiology, specifically related to pesticide-related poisonings Specialty: Fellows and advanced students specializing in occupational and environmental health/medicine/nursing 1a. Apply validated epidemiologic and biostatistical principles and techniques to analyze injury/illness data in defined populations 1b. Understand temporal relationship between exposure and symptoms (Nursing) 1c. Understand and apply advanced courses in toxicology 2a. Apply individual patient interventions to prevent or mitigate exposure and/or resultant health effects 3a. Develop, implement, evaluate and refine screening programs for groups to identify risks for disease or injury and opportunities to promote wellness 3b. Apply community-based interventions to prevent or mitigate exposure and/ or resultant health effects 44

53 Table 6 (continued) 4. Information and Resources 4a. Identify and access information on pesticides 4a. Strengthen skills from Basic competencies 4b. Be aware of importance of information on pesticide labels 4c. Be able to locate resources including Web-based information, print materials, Material Safety Data Sheets (MSDS), and poison control centers 4b. Demonstrate ability to locate leading informational resources and experts for health care providers Competency II: Diagnosis and Assessment Basic Advanced History Taking Differential Diagnosis Diagnosis 1a. Be able to take environmental history 1b. Be aware that signs and symptoms of pesticide exposure may be non-specific (there is nothing pathognomonic about most pesticide symptoms) 1c. Be able to consider pesticides in differential diagnosis (pesticide exposures may result in health effects common to similar diseases) 1a. Strengthen skills from Basic competencies 1b. Ask patients 2-3 screening questions (students need to know how to take a full environmental history before they are able to ask screening questions) 1c. Identify signs and symptoms of overexposure to a wider range of pesticides 1c. Recognize signs and symptoms of pesticide overexposure, with priority given to widely-used pesticides with identifiable symptoms, such as cholinesterase-inhibitors and pyrethroids 1d. Be able to diagnose pesticide-related illnesses related to organophosphates and pyrethroids 1e. Properly utilize cholinesterase testing 1d. Perform a complete and focused physical examination as indicated (ACOEM) 4a. Use appropriate written and computerized databases (e.g. MSDS, Registry of Toxic Effects of Chemical Substances [RTECS]) to identify hazardous ingredients of chemical agents Specialty 1a. Determine the nature and extent of potential pesticide poisoning or overexposure considering routes of exposure and routes of absorption 1b. Detect, in so far as possible, pre-clinical or clinical effects arising from chemical exposure 1c. Be able to order/ interpret appropriate diagnostic tests 1d. Effectively diagnose pesticide-related illnesses 1e. Provide consultation on diagnosis 1f. Identify at risk populations, including children 1g. Collaborate with other disciplines such as industrial hygiene, sanitarians, Cooperative Extension 45

54 Table 6 (continued) Competency III: Treatment/Intervention/ Referrals/Follow-up Basic Advanced 1. Treatment 1a. Effectively treat health conditions related to pesticide exposures (Medicine) 1a. Strengthen skills from Basic competencies 1b. Effectively treat health conditions (Nursing) 2. Intervention 2a. Advise patients on how to decontaminate patient and environment following exposure 2a. Strengthen skills from Basic competencies 2b. Provide specific guidance on how to decontaminate patient and environment following overexposure 3. Referrals 3a. Refer to appropriate specialist (i.e. occupational medicine/nursing, industrial hygenist, environmental health specialist, Cooperative Extension) (Medicine) 3a. Strengthen skills from Basic competencies 3b. Make appropriate referrals for medical diagnosis (Nursing) 4. Follow-up 4a. Arrange appropriate follow-up (Medicine) 4a. Strengthen skills from Basic competencies 4b. Arrange appropriate follow-up (Nursing) Specialty 1a. Be able to effectively treat specific pesticide-related health conditions 2a. Identify and prescribe appropriate personal protective equipment and engineering controls for specific pesticides 2b. Develop and manage a comprehensive occupational health program 3a. Provide consultation on treatment, intervention, and referrals 4a. Provide consultation on follow-up 46

55 Table 6 (continued) Competency IV: Risk Communication, Advocacy, & Ethics Basic Advanced Specialty 1. Risk Communication 1a. Provide guidance and education to patients on how to minimize exposures to pesticides, and about the basic routes of exposure and absorption 1b. Advise patients to read pesticide label 1c. Refer patients to appropriate resources 1a. Strengthen skills from Basic competencies 1b. Communicate on issues of risks and public health protection to the general public 1c. Publish research and intervention findings in the professional literature 1a. Communicate with media, the public, and policy makers on issues of scientific uncertainty 1b. Provide expert testimony on behalf of patients and communities 1c. Publish research and intervention findings in the professional literature 2. Advocacy 2a. Advocate on behalf of patients 1a. Communicate with media, the public, and policy makers on issues of scientific uncertainty 1b. Provide expert testimony on behalf of patients and communities 3. Ethics (under development) Competency V: Reporting Basic Advanced Specialty Reporting 1a. Understand importance of surveillance and incident reporting 1a. Strengthen skills from Basic competencies 1a. Interact with worker compensation system efficiently and effectively 1b. Understand case reporting requirements for pesticide exposures 1c. Report concerns about pesticide exposure situations to appropriate authorities 47

56 Table 6 (continued) Competency VI: Legislative and Regulatory Knowledge Legislative and Regulatory Knowledge Basic Advanced 1a. Understand that several pieces of federal law require health care providers to address pesticide poisonings 1b. Understand that 15 states have mandatory surveillance systems, and that 31 states have some form of reporting requirements 1a. Know the specific components of FIFRA, OSHA, TOSCA and WPS that reference health care providers Specialty 1a. Influence policy regarding pesticides and public health 48

57 EDUCATION COMPONENT C: Assess Educational Settings Statement Conduct an assessment of the target audience of educational institutions to determine: (a) amount of existing coursework, (b) faculty members current knowledge and skill levels, and comfort with teaching pesticide-related topics, and (c) how faculty and educational institutions will best respond to educational programs and informational resources. This assessment will be comprised of a literature review, surveys, and focus groups. EDUCATION Expected Outcomes Baseline data indicating the level of education currently taking place in academic institutions, current curricular content and emphasis on pesticides/environmental health, current knowledge of teaching faculty, and best mechanisms to reach and train faculty to teach. Target Audience Awareness and Motivation: This component targets academic institutions to determine their 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 Activities Activity #1 Conduct a literature review to locate survey data and evidence of level of training in educational institutions. Activity #2 Where literature review is lacking in data, conduct a combination of audience assessment activities, including focus groups and interviews, to effectively collect baseline data and draw conclusions on the following questions: To what extent are the recognition and management of pesticide-related health conditions taught in the targeted academic institutions? What is the extent of the knowledge, attitude, and skill base of faculty members with regard to pesticide issues? Are they at the stage of needing to raise awareness, improve their knowledge and skills, or provide them with resources? 49

58 EDUCATION What is the extent of faculty comfort level with teaching this topic area? What do faculty need to feel more comfortable about teaching this topic? What resources, and in what format (e.g., traditional lecture material, teaching modules, Web-based, audio cassette, CD, videoconference, satellite), do academic institutions most need to teach about this topic? Activity #3 Produce a final report with recommendations for use in the development of the initiative. Stakeholders Professional associations that represent academic institutions Academic institutions Faculty curriculum committees Faculty members Students Evaluation of Outcomes/Indicators of Success Comprehensive literature search documenting the findings of studies that have surveyed academic institutions and deans. Report with baseline data, conclusions, and recommendations. Background Any good plan has at its core a strong assessment component to collect baseline data on existing knowledge and skills, as well as to determine the most effective mechanism for reaching the target population. The importance of assessing educational institutions to determine what is already in place, and how best to structure the educational interventions was emphasized by initiative participants during the development of the Implementation Plan. This component will collect vital information not only for this initiative, but also for the entire field of health care provider education. 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 people lie at the beginning of the continuum where they will respond best to activities that raise their awareness and motivate them to care about this issue? Or are they ready to make changes in their curricula 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. 50

59 EDUCATION COMPONENT D: Secure Official Endorsements Statement Ensure the integration of the core competencies outlined in the National Guidelines into educational institutions by securing the official endorsements and support of key professional organizations and decision-making bodies. EDUCATION Expected Outcomes Professional organizations, licensing and accrediting bodies, administrators, and educators will agree that these competencies are essential to the education of primary care providers and will integrate or support their integration into core curricula. Target Audience Awareness and Motivation: This component targets key accrediting bodies and associations for academic institutions, along with academic deans and faculty committee chairs. The emphasis here is on raising awareness and motivating decision-makers to bring about change in academic institutions that prepare health care providers. Maintenance/Sustainability: This component also targets key professional associations to endorse 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 the educational settings for health care provider training. Proposed Activities Activity #1 Promote competencies with professional and decision-making organizations and academic institutions (along with the case statement) through strategic meetings and outreach. Highlight the specific recommendations in the National Guidelines on competencies, along with specific examples of how an educational institution could integrate the content into curricula. Activity #2 Publish editorials in nationally recognized journals promoting the idea of integrating specific strategies from the National Guidelines into curricula. 51

60 EDUCATION Activity #3 Develop a position paper on the need for competencies to be posted on the Internet, and for use in meeting with decision-making bodies. Activity #4 Identify and promote incentives for faculty to teach core competencies, including financial incentives in the form of grants, faculty development, curriculum development, and research, instructional teaching and training aids, expert consultants, clinical access, release time for faculty development, curricula development, and establishing appropriate clinical sites and teaching venues. Stakeholders Professional specialty organizations, licensing boards, accreditation/certification bodies National professional associations Evaluation of Outcomes/Indicators of Success New position papers by targeted organizations that support the integration of recommended pesticide content into curriculum. New requirements by professional decision-making bodies that require institutions to teach about health effects from pesticides. Published journal articles in professional newsletters and peer-reviewed journals. Background The success and sustainability of this initiative will only be achieved if the institutions themselves find ways to integrate pesticide-related content into health professional education. The best mechanism to reach such organizations is for individuals involved in this initiative to meet oneon-one with key leaders and offer them simple and easy ways that they can endorse and/or adopt this Implementation Plan. 52

61 EDUCATION COMPONENT E: Strengthen and Build Faculty Champions Statement Create and support faculty champions within medical and nursing schools to teach environmental health and pesticide education in the curriculum, and to bring about change within their institutions. A champion, for purposes of this initiative, is defined as a faculty member who takes a leadership role in integrating environmental health and pesticides into his/her institution in a sustainable fashion. This component is designed to ensure that a strong cadre of faculty champions is developed across the country who will lend expertise and support for this effort in their institutions and surrounding communities. EDUCATION Expected Outcomes Funding of 146 faculty champions, including one faculty champion in all 126 academic health centers 1 in the United States, plus an additional 20 faculty champions in 20 other higher education institutions to ensure a balance of medicine and nursing faculty as well as representation from diverse institutions. Additional support for 10 of the academic health centers to serve as regional technical assistance centers. Target Audience Champion Building: This component targets faculty members who are ready to become a part of a cadre of faculty from across the country who will teach courses, integrate competencies into curriculum, and serve as a model for how to integrate environmental health and pesticides into health professional education. The target audience is convinced of the importance of this issue and has enhanced its knowledge and skill level. Proposed Activities Activity #1 Identify and select several model academic setting programs based on the existing work of faculty across the country, with specific focus on primary care faculty members. Hold a small 1 While the organization and structure of academic health centers vary, every center comprises an allopathic and osteopathic school of medicine, at least one other health professional school or program, and one or more owned or affiliated teaching hospitals. 53

62 EDUCATION invitational workshop of model programs and develop several models on which to base the funding for all 146 academic institutions. Activity #2 Develop key required elements for a model faculty champion program including the following: Faculty member with 25% time availability. Faculty member trained in primary care (defined as pediatrics, family practice, internal medicine, obstetric/gynecology, emergency medicine, or preventive medicine/public health). Commitment of staff time (part time health educator and administrative support). Existing and proposed partnerships within the academic health center to ensure that the faculty champion s work reaches all schools within the institution. Teaching and curriculum development component, including baseline analysis of student knowledge and skills. Institutional change component with specific strategies articulated for changing institutions to support teaching environmental health/pesticides. Community-based sites for student practicum, internships, residencies. Advisory Committee, inclusive of environmental health expertise, curriculum committee members, community members. Opportunities to link teaching with research activities. Plan of action for 5-year integration. Evaluation component. Activity #3 Establish 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 national coordinating office are to: Develop the RFA with the federal agencies; manage the application and grant-making processes. Produce a faculty guidebook with model programs on which faculty are asked to base their activities. Convene faculty for a working session to introduce model programs and work with project design. Annual meetings will be held in subsequent years. Set up ongoing technical assistance and evaluation effort with faculty members to be available for the length of the project. 54

63 Establish regular forms of communication among faculty members, including regional meetings, Web-based interactive activities, online submission of teaching modules or other curricular pieces, and formative and summative evaluation. Present ongoing findings at national conferences and assist on national issues as they may arise. Coordinate entire evaluation effort. Activity #4 Release RFA to academic institutions for a 5- year grant funded effort. Ensure diversity in faculty and disciplines selected. Publicize RFA process. Select 146 faculty champions. Applications must include all items listed in Activity #2 along with a timeline for completion. 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 Incorporate a capacity-building mechanism into the grant-making process by creating 10 regional networks of faculty members where the exchange of technical assistance can take place. To achieve this, one academic center in each region would be granted additional funding (through a competitive process) to provide technical support to new faculty champions in that region. In this way, the program will help transfer knowledge and expertise from existing champions to new faculty members, while also supporting the additional time spent by existing champions. Activity #5 Launch initiative with the announcement of the 146 faculty champions and 10 regional centers receiving additional funding. Faculty efforts will last 5 years with specific increments identified for evaluation, workshops, submission of work, and activities via the Websites, and quarterly/ annual reviews. Throughout the entire process, the national coordinating organization will build the cadre of faculty nationwide. (See Table 7). Stakeholders Collaborating federal agencies Key association for health professional schools National coordinating body 55

64 EDUCATION Table 7: Proposed Design of Faculty Champions Project Institution Funded Activities Funded Individuals Funded Length of Funding National Overall coordination Project Director, 6 years (design, Coordinating and management (100% FTE), Coordinator implementation Organization 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 Coordinator chosen 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 support health centers + 20 in academic institutions, representing diverse including inclusion populations and in curriculum, and nursing schools) institutional change Evaluation Team a Formative and Evaluation staff Portions of all 6 years summative evaluation a may be subcontracted by the national coordinating organization. Evaluation of Outcomes/Indicators of Success The entire component will be evaluated based on the following indicators: Project Outcomes (1-5 year funded project) 146 institutions with documented integration of pesticides/environmental health into curriculum. 146 institutions with increase in students basic knowledge and skills in pesticide/ environmental health. 146 institutions with increased FTE time devoted to environmental health. Increase in number of practice/field experiences in environmental health sites Increase in environmental health research activities. Project Outcomes (post 5-year project) Increase in new researchers investigating environmental health. Increase in number of primary care providers out of the pipeline who address environmental health in practice and research. 56

65 Sustainable institutional change in majority of 146 institutions. Changes in the way health professionals address environmental health (measure of overall effectiveness). Background This component proposes a significant investment of funding to build a strong cadre of faculty champions. The funding would pay for part of a designated faculty FTE, plus a half-time position for administrative and content support at 146 institutions. The funding would also support 10 regional centers headed by an existing faculty champion and designed to provide technical assistance and support to new faculty members in the region. The champion would use a variety of educational methodologies (required courses, integration within existing courses, field experience, and links with community members and organizations), and would link with other schools, departments, and organizations as part of a national network of champions. In particular, it is recommended that faculty champions coordinate with model practice sites (see Practice Component E, p. 75). The intent is for the faculty champion to base his/her activities on selected model programs that have already undergone evaluation. EDUCATION The idea of creating and strengthening champions of pesticide/environmental health education came out of the Education Workgroup s discussion of how important a role individuals can play at an institution. A threshold level of funding and security of funding is needed to encourage institutions to hire and/or nuture pesticide/environmental health champions. A multi-year commitment is also necessary to make it worthwhile both for the institution and the champion. Much of the champion s time should be spent institutionalizing the pesticide/environmental health component by developing faculty interest/knowledge and integrating it into curriculum, both in medicine and nursing disciplines. Otherwise, when the grant funding ends, the environmental health/pesticide component is likely to be viewed as nice but not necessary and may disappear at the next curriculum change cycle. The proposal developed 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 is important to make the funding equal across academic health centers. This component will fund 126 academic health centers and an additional 20 institutions to ensure a balance between medicine and nursing, and the inclusion of diverse institutions. Faculty champions will be selected equally from the disciplines of medicine and nursing. Faculty champions will also be selected from primary care. Given that some institutions already have faculty champions, the project 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 faculty champions in the region. The entire project will build upon other faculty champion models that have been created for other subject areas nationwide. 57

66 EDUCATION EDUCATION COMPONENT F: Create Teaching Incentives Strategy Influence the appropriate boards, organizations, and institutions that create Board exams and set curriculum requirements to include several key competencies on pesticides and environmental health. Expected Outcomes Questions on Board exams Changes in curriculum requirements Target Audience Awareness and Motivation: This component targets decision-making organizations that set curriculum requirements, entities that write Board and certification examinations, and faculty who teach based on requirements and exams. This component is designed to motivate and convince these decision-makers to integrate into their requirements and exams small components that address the health effects from pesticide exposures. This component will also provide ready-made language on requirements and/or exam objectives and questions. Proposed Activities Activity#1 Conduct 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 questions by key decision-making bodies. Activity #2 Develop a succinct strategy for approaching the organizations/decision-making bodies that develop Board and other examinations, including specific recommendations for educational objectives, questions and language changes. Action items include: Convene a working group of high level external partners and key federal agencies to develop strategy/position paper. This group should be drawn from the Association of American Medical Colleges, the American Association of Colleges of Nursing, the American 58

67 Association of Occupational Health Nurses, the American College of Occupational and Environmental Medicine, the American Medical Association, the American Nurses Association, the American Association of Physical Assistants, and American College of Nurse Midwives. In addition, federal agencies could include National Institute of Environmental Health Sciences, National Institute of Occupational Safety and Health, EPA, and Health Resources and Services Administration. Create a strategy that recommends specific content (per National Competency Guidelines in Education Component B) and insertion points into specific Board exams and specialty requirements. Strategy will also set targets for change. EDUCATION Activity #3 Contact decision-making bodies and provide with them with specifically tailored position paper and recommended changes to questions, exams, and requirements. Include the endorsement of the relevant working group organizations. Identify Boards and schedule using the following outline of priorities: Short-term Priorities Medicine: United States Medical License Examination (Steps 1, 2, 3) Board Examinations in Family Practice, Pediatrics, Internal Medicine, Ob/Gyn, Emergency Medicine Nursing: AANC generalist examinations Nurse practitioners adult, pediatrics, family, gerontological (ANP, PNP, FNP, GNP) Nurse midwives American College of Nurse Midwives (ACNM) Clinical nurse specialists (CNS) Longer-term Priorities Physicians Assistants Pharmacists Basic Nursing Genetic Counselors 59

68 EDUCATION Stakeholders Key national decision-making bodies for curriculum changes, requirements, and examinations National professional association Key federal agencies involved with health profession education Faculty members Evaluation of Outcomes/Indicators of Success Increase in the number of questions in the examination pool and on each examination as compared with the initial assessment. Changes in requirements for primary care disciplines (pediatrics, family practice, internal medicine, preventive medicine/public health, emergency medicine and obstetrics and gynecology) to include pesticides/environmental health. Background One way to motivate change in curriculum is to convince the medical and nursing examination boards of the importance of environmental health in the coming years, and urge them to incorporate environmental health questions on their exams. This would also be one of the better ways to institutionalize the subject matter over the long term. Some of the boards are expected to be receptive to a concerted effort in this area; for example, the Residency Review Committee for Pediatrics in 1997 adopted two recommendations on children s environmental health. 60

69 Practice Settings The second prong of the strategy is the practice setting. Practice settings, for purposes of this 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 the Migrant Clinicians Network, to name a few. The following components cut across the continuum of systemic change from raising awareness and assessment, to development of expected practice skills, to the support of model practices and system-wide incentives. Component A: Make the case for practitioners Develop an effective case statement to convince primary care providers of the need to incorporate environmental health and pesticide awareness into their practice settings. Component B: Define practice skills and guidelines Produce National Guidelines that recommend practice behaviors 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 into practice and training settings; and provide access to relevant resource materials. PRACTICE Component C: Assess knowledge and skills of practitioners Conduct 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 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 practice skills into practice settings by securing the official endorsements of key professional organizations and decision-making bodies specific to practice. Component E: Demonstrate model programs Mobilize practice settings to become population-specific and to incorporate environmental considerations (specifically pesticides) into prevention, education, diagnosis, and treatment. Achieve incremental, site-specific improvements in identification, early intervention, and prevention, as well as in measures of practice-specific health outcomes. By 2010, half of all primary health care practice settings in 61

70 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 incentives to incorporate appropriate prevention, recognition, and management of pesticide-related health conditions into health care practices. Specifically: (1) provide grant support to practicing providers for interventions and research related to pesticide poisonings and exposures, (2) create free, readily available opportunities for continuing medical education involving pesticides and environmental health, (3) increase providers awareness of the value of taking an occupational and environmental history for optimizing Evaluation and Management (E&M) coding and billing, (4) require knowledge of environmental health issues for certification and recertification, (5) require pesticide poisoning reporting for worker compensation reimbursement and automatic worker compensation reimbursement for workup of suspected occupational pesticide-related health conditions, and (6) promote documentation of occupational and environmental history in medical records via incorporation into quality assurance/quality control mechanisms. PRACTICE 62

71 PRACTICE COMPONENT A: Make the Case for Practitioners Statement Develop an effective case statement to convince primary care providers of the need to incorporate environmental health and pesticide awareness into their practice settings. Expected Outcomes A written case statement that documents the key points of why practicing health care providers should care about the environments in which their patients live, especially with regards to potential pesticide poisonings and exposures, along with the accompanying scientific literature to support the need for well educated health care providers. This statement will be linked with the case statement for educational settings. Endorsement of the case statement by leading national professional associations and national bodies that work with practitioners. Target Audience Awareness and Motivation: This component is targeted at decision-makers and key strategic organizations that need to be convinced that the issue of pesticide poisonings and the need to educate health care providers about this issue are relevant to the practice settings of health care providers. This component also targets primary care providers who are not yet convinced that this is an appropriate subject for a national plan. PRACTICE Proposed Activities Activity #1 Research and develop a case statement, solicit peer review, and finalize with the input of key stakeholder groups in the field. The target audience for the case statement is the practicing health care providers and the organizations that work with them. Points to be covered in the case statement: Importance of environmental health training and the breadth of the problem of pesticiderelated health conditions. 63

72 Convincing arguments for why pesticides should be part of what health care providers address in their practice settings, with cited scientific data, along with relevance to the practice of health care and public health. Compelling arguments to gain the attention of primary care providers despite the fact that their time and attention are in high demand elsewhere. Emphasis that practitioners do not need to become experts, and reassurance that experts are available to work with them on specific clinical cases and/or community concerns. Reassurance that user-friendly tools exist for practitioners to use, along with user-friendly guides for teaching pesticide issues to practitioners through continuing education. Recommended amount of time to dedicate to pesticides in the clinic that is reasonable given the other demands on practice settings. PRACTICE Activity #2 Promote case statement through effective dissemination mechanisms, including print and Internet information sources. Activity #3 Publish journal or newsletter articles in professional journals and publications. Activity #4 Hold strategic meetings with professional associations and national leaders to seek their endorsement of the case statement. This includes identifying a subset of decision-makers who can be influenced by the case statement. Stakeholders Professional associations Recertification bodies Continuing education organizations Evaluation of Outcomes/Indicators of Success Case statement Published articles in professional journals and newsletters Position papers developed and adopted by professional associations 64

73 Background It is recognized that many key decision-makers are still unconvinced that this is an issue of concern. Although the supporting documentation exists, there is a need to pull the information together in a succinct case statement directly designed for practitioners. PRACTICE 65

74 PRACTICE COMPONENT B: Define Practice Skills and Guidelines Statement Produce 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 into practice and training settings; and provide access to relevant resource materials. Expected Outcomes PRACTICE National Pesticide Practice Skill Guidelines which recommend practice skills, content, insertion points into practice and training settings, and resources. The Guidelines will be completed in mid Endorsement of National Guidelines by leading national professional associations. Target Audience Readiness to Change: This component is targeted at administrators of clinics and health care delivery systems, providers of professional development, and practitioners. The component assumes that the administrators and practitioners are convinced of the importance of this topic and are ready to make changes in their practices. Proposed Activities Activity #1 Define the basic practice skills for practice settings to ensure that all practicing primary care providers are 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 been completed, as shown in Table 8 on page 68. The intent of the table is to define expected practice skills for all practitioners. This table will link with a complementary document being created for educational settings. Activity #2 Produce National Guidelines that will guide practitioners on the recognition and management of pesticide-related health conditions. A complementary report will focus on the educational settings where primary care providers receive their training. 66

75 The National Guidelines will be drafted by a team of experts and will contain the following components: Recommended practice skills. Relevant content for each practice skill. Suggested points of insertion into practice settings. 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 and nurses, and identify relevance to pesticide expected practice skills. (The team is expected to conduct a literature review, but not to conduct a full survey and/or questionnaire of existing 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 training programs (including continuing education, distance learning, etc.), for physicians and nursing. Develop a map of creative delivery mechanisms highlighting potential points of insertion of pesticide-related content in such training programs. 5) Identify resources specific to each expected practice skill that can be added to a computerized database of educational resources. PRACTICE 6) Develop recommendations for designing and implementing workshops and educational opportunities with professional associations and continuing education. The report will be designed as a user-friendly guide on how to integrate pesticides content into practice skills. It will serve as a supplementary practitioner guide to the Recognition and Management of Pesticide Poisonings. The report will not contain actual training modules or resources, but instead will provide a listing of relevant resources and how to locate them. Activity #3 Promote the National Guidelines with key stakeholders and solicit official endorsements and organizational support of report, including dissemination to their members. Stakeholders National professional associations for practicing primary care providers Practicing health care providers who have already developed tools and practice models 67

76 Evaluation of Outcomes/Indicators of Success The National Guidelines will include defined practice behaviors, content areas, insertion points, examples as necessary, and recommended resources. Endorsement by key professional organizations for providers. Background The preliminary list of Expected Practice Skills shown in Table 8 is recommended as a useful goal for primary care providers seeking to provide the highest quality care to their patients. This list will form the starting point for future efforts. Table 8: Expected Practice Skills Preliminary Outline PRACTICE 1. Take an environmental and occupational health history. Providers should be able to take a basic environmental and occupational history to determine if a temporal relationship exists between exposure and symptoms. Ask patients 2-3 screening questions that would elicit possible exposure to a number of environmental factors (including but not limited to pesticides). Take an environmental health history with questions regarding where the patient lives, works, and plays. 2. Recognize the signs and symptoms of pesticide exposures and appropriately manage or refer patients. Recognize the signs and symptoms of pesticide exposures (both acute and chronic). Providers should be able to treat and manage health conditions associated with pesticide exposure or refer patients to appropriate specialists and resources, and follow up appropriately. Diagnose pesticide-related health conditions using appropriate testing procedures and treat pesticide exposures. 3. Identify risk factors for pesticide exposure and resulting health effects. Identify risk factors for pesticide exposure (e.g. occupation, location of home, susceptible populations such as children). continued on the following page 68

77 Table 8 (continued) Identify environmental factors that may possibly be linked to patient illness to ensure that chronic pesticide exposures are addressed. 4. Demonstrate key principles of environmental/occupational health and epidemiology and population-based health. Demonstrate an understanding of principles of environmental and occupational health, and epidemiology. Understand the temporal relationship between exposure and symptoms. Recognize that others may be ill (co-workers, family) and get a timeline of health problems for these or consult public health authorities for help in evaluating exposures. 5. Take steps to report pesticide exposure and support surveillance efforts. Understand the importance of surveillance and reporting. Be able to access and report data for local, regional, and national surveillance programs. Report cases involving pesticide exposures as required. Report concerns about pesticide exposures to the appropriate authorities, such as local 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. 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. Demonstrate an understanding of population-based health. Demonstrate knowledge about the environment in which the practice is situated, with specific understanding of communities that may be at-risk for pesticide exposures. Be aware of, and access, the resources available within the community and in the state or region, that could assist in pesticide exposures and illness. PRACTICE 7. Provide prevention guidance/education to patients. Provide guidance to patients on how to prevent pesticide exposures. Advise patients and provide basic education about pesticide exposure. Counsel patients about minimizing unnecessary use of pesticides, refer patients to appropriate experts on integrated pest management. Address the whole patient in the context of his/her life and/or community (e.g., link to social services, etc.). 69

78 PRACTICE COMPONENT C: Assess Knowledge and Skills of Practitioners Statement Conduct 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 programs and informational resources. This assessment will be comprised of a literature review, surveys, and focus groups. PRACTICE Expected Outcomes Baseline data indicating the level of training currently taking place in practice settings, current knowledge of practicing providers, and identification of best mechanisms to reach and train providers, and to equip them with user-friendly tools. Target Audience Awareness and Motivation: This strategy targets health care practitioners to determine their level of awareness; their motivation, or lack of motivation, for this topic; their knowledge and skills base; and the most effective ways to reach them through educational interventions, model programs, and resources. Proposed Activities Activity #1 Conduct a literature review to locate survey data and evidence of level of knowledge, attitude and skills of health care providers related to pesticide-related health conditions. Activity #2 Where literature review is lacking in data, conduct a combination of audience assessment activities, including surveys and focus groups, to be able to effectively collect baseline data and draw conclusions on the following questions: To what extent are the recognition and management of pesticide-related health conditions included in the continuing professional development of primary care providers? What is the extent of the knowledge, attitude, and skill base of practicing primary care providers with regard to pesticide issues? Are they at the stage of needing to raise awareness, improve their knowledge and skills, or obtain resources? 70

79 What level of comfort do practitioners have with addressing pesticides with their patients and in communities? What do practitioners need to feel more comfortable in addressing pesticides in their practice settings? 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 #3 Produce a final report with recommendations for use in the development of the initiative. Stakeholders Professional associations that represent practitioners Continuing education programs, organizations that offer continuing education Practicing clinics and health care delivery systems Practicing providers It is not clear that we really know what [resources] health care providers want and need. Allen James, MBA, CAE Responsible Industry for a Sound Environment Evaluation of Outcomes/Indicators of Success Comprehensive literature search documenting the findings of studies that have surveyed practicing primary care providers. Report with baseline data and conclusions/recommendations for implementation of the Initiative. Background Any good plan has at its core a strong assessment component to collect baseline data on existing knowledge and skills, as well as to determine the most effective mechanism for reaching the target population. This component will collect vital information not only for this initiative, but also for the entire field of health care provider education. The assessment will also include a chance to determine where the target population presents 71

80 itself along the continuum of change described in the section on Target Audience. Do most people lie at the beginning of the continuum where they will respond best to activities that raise their awareness and motivate them to care about this issue? Or are they ready to make changes in their practice 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. PRACTICE 72

81 PRACTICE COMPONENT D: Secure Official Endorsements Statement Ensure the integration of the expected practice skills into practice settings by securing the official endorsements of key professional organizations and decision-making bodies. Expected Outcomes Professional organizations, influencing bodies, and practitioners will agree that the expected practice skills are essential to the ongoing training of primary care providers and will integrate or support their integration into practice settings. Target Audience Awareness and Motivation: This component targets key recertification and continuing education bodies and professional associations for practitioners. The key emphasis here is on raising awareness and motivating decision-makers to bring about change in practice that provide lifelong learning to health care providers. Maintenance/Sustainability: This component also targets key professional associations to endorse 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 the practice settings for health care provider training. PRACTICE Proposed Activities Activity #1 Promote expected practice skills and case statement with professional organizations to garner their involvement and support in implementing interventions to improve the knowledge, attitudes, and skills of practicing health care providers. Activity #2 Highlight 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 ongoing training of providers. 73

82 Activity #3 Publish editorials in nationally recognized journals on specific strategies from the National Guidelines, along with user-friendly tools for providers. Activity #4 Develop a position paper on the need for expected practice skills, to be posted on the Internet and for use in meeting with credentialing bodies and decision-makers. Activity #5 Identify and promote incentives for professional associations to be involved in the initiative, including financial incentives in the form of grants, technical assistance for clinics, communitybased interventions and research, instructional teaching and training aids, expert consultants, clinical access, release time for professional development, and establishing appropriate clinical sites for additional training. PRACTICE Stakeholders Professional specialty organizations Licensing boards National professional associations Evaluation of Outcomes/Indicators of Success New position papers by targeted organizations that support the integration of recommended pesticide content into practice settings. New requirements by professional decision-making bodies that require professional education to teach about health effects from pesticides. Published journal articles in professional newsletters and peer-reviewed journals. 74

83 PRACTICE COMPONENT E: Demonstrate Model Programs Statement Mobilize practice settings to become population-specific and to incorporate environmental considerations (specifically pesticides) into prevention, education, diagnosis, and treatment. Achieve incremental, site-specific improvements in identification, early intervention, and prevention, as well as in measures of practice-specific health outcomes. By 2010, half of all primary health care practice settings in the United States should incorporate environmental considerations in prevention, education, management, and referral of pesticide-related health conditions. Expected Outcomes Demonstration projects (distributed geographically across the United States) that model practice settings where pesticide-related health conditions are an integrated part of the provision of care and community outreach. Evaluation of demonstration models and creation of a models that work guide for the field and other practice settings. Creation of a tool kit that can be used by other practice settings that want to set up a model program. Launching of nationwide effort to redesign 50% of all practice settings. PRACTICE Target Audience Maintenance/Demonstration: This component targets specific practice settings that are ready to become part of a cadre of model practices across the country that will change the way they practice, specifically addressing potential health effects from pesticide poisonings and exposures. The target audience in this case has been convinced that this is an important issue and has increased its knowledge and skills in this area. Model practices may also be located in areas of higher impact, such as farmworker clinics and urban settings. Proposed Activities Activity #1 Mobilize practice settings that currently address environmental health/pesticide issues. Identify current leaders among practice settings and encourage them to spread the word on what they already do. 75

84 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 practice model. Ensure that the funded sites represent the range of practice settings and the breadth of pesticide issues (e.g., urban and rural, agricultural and non-agricultural, diversity of cultures and literacy rates). Ensure that some programs are located in states with pesticide reporting requirements. Activity #2 (option 2) Secure funding, create a program description, and develop an RFP to solicit small proposals from 100 clinical/community sites to receive financial support over 1.5 years to create a practice model. Ensure that the funded sites represent the range of practice settings and the breadth of pesticide issues (e.g., urban and rural, agricultural and non-agricultural, diversity of cultures and literacy rates). Ensure that some programs are located in states with pesticide reporting requirements. PRACTICE Activity #3 Define the major components of the proposed practice model, allowing for flexibility by the specific site. Ensure that the models are grounded in theories and experience about how change actually happens so as to learn from other experiences in practice settings. One model that has been recommended is the Diabetes Collaborative (see box on page 78). Activity #4 Establish a coordinating body to manage the project and the creation of the consortium of pilot sites, and to create the plan of action for the project. Among the tasks of the national coordinator are: Create a consortium of the pilot sites that use the proposed model as a guide for developing their own specific practice intervention plan (including what they want to do, the intervention, the evaluation and the implementation of the proven change). Build a technical assistance component that can work with sites in designing the intervention, piloting the intervention and evaluating its success. Convene pilot sites on a regular basis by conference call and in-person meetings to share success stories, challenges, and lessons learned. Establish an evaluation mechanism for the sites and the national project to determine the success of the creation of new models. Evaluation would be both formative and summative. Activity #5 Launch nationwide effort to redesign 50% of practice settings based on findings from the model sites. 76

85 Stakeholders Professional associations Practice settings National coordinating organization Funding agencies and partners Organizations that have created practice change models Evaluation of Outcomes/Indicators of Success RFP completed and funding secured for pilot program. Chosen sites underway in developing practice models. Five to ten practice change models with evaluation components and identified success stories. Publication of model programs. Effective dissemination of practice models nationwide. Enhanced reporting of cases. Background The key to changing practice is demonstrating how changes in day-to-day activities actually make a difference in health outcomes of patients and communities. This strategy was generated by the Practice Workgroup as a way to model expected changes and to evaluate what practice changes actually lead to the overall goal of the initiative to increase the recognition, management and prevention of pesticide poisonings and exposures. There are two recommended options for this strategies: (1) fund a large number of demonstration practice sites to make several small practice changes and evaluate the outcome, or (2) fund a small number of demonstration 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). PRACTICE 77

86 The 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. PRACTICE MODELS FOR CHANGE: THE DIABETES COLLABORATIVE 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: 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. 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. 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. 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 78

87 PRACTICE COMPONENT F: Create Incentives for Change Statement Identify 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 research related to pesticide poisonings and exposures, (2) create free and readily available opportunities for continuing education involving pesticides and environmental health, (3) increase providers awareness of the value of taking an occupational and environmental history for optimizing Evaluation and Management (E&M) coding and billing, (4) require knowledge of environmental health issues for certification and re-certification, (5) require pesticide poisoning reporting for worker compensation reimbursement and automatic workers compensation reimbursement for work-up of suspected occupational pesticide-related health conditions, and (6) promote documentation of occupational and environmental history in medical records, via incorporation into quality assurance/quality control mechanisms. Expected Outcomes Increased attention paid by primary care providers to pesticide poisoning and exposures based on incentives to change practice. Creation of new or improved incentives in the following areas: monetary incentives, legal incentives, community-based incentives, and peer/professional incentives. PRACTICE Target Audience Awareness and Motivation: This component targets health care system administrators and funders to create incentives for providers to address pesticide-related health conditions. This component is designed to motivate and convince decision-makers that specific changes can and 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 Activities Activity #1 Provide grant support to practicing providers for interventions and research related to pesticide poisonings and exposures: 79

88 Urge federal agencies (CDC, NIH, EPA, HRSA), state agencies, and private foundations to support intervention and research projects conducted by practicing primary care providers. Publicize models developed through grant support. Create a centralized source of information about grants and grantees. Activity #2 Create free and readily available opportunities for continuing education involving pesticides and environmental health: PRACTICE Connect continuing education (CE) courses on pesticides to major national meetings. Offer free CE credits in a variety of settings. Offer CE credits in local settings and support experts to go out to local clinics to provide pesticide education. Establish free, Web-based continuing education. Encourage and fund NIOSH Education and Research Centers (ERCs) to hold local continuing education courses on pesticides. Address barriers such as competing priorities for providers, cost of hosting continuing education programs, and lack of provider interest. Activity #3 Increase providers awareness of the value of taking an occupational and environmental history for optimizing Evaluation and Management (E&M) coding and billing. See next page for a brief summary of how E&M coding could be upgraded. Activity #4 Require knowledge of environmental health issues for certification and re-certification: Identify priority professional certifying bodies. Recruit high-profile supporters from each of the relevant disciplines. Create sample objectives and questions on environmental health issues. Approach certifying bodies about including questions. Coordinate outreach to the certifying bodies. Address barriers such as institutional inertia, competing priorities, and lack of perceived problem. 80

89 EVALUATION AND MANAGEMENT CODE UPGRADING According to the 1997 Health Care Financing Administration Documentation Guidelines, in order for a provider to bill for a comprehensive visit for a new outpatient, a new inpatient, or a new consult, the provider must document taking all of the following: a past medical history (PMH), a family history (FH), and a social history (SH). The social history is defined as an age-appropriate review of past and current activities. For follow-up visits and emergency department visits to be designated as comprehensive, two out of the three histories must be documented. It may be possible to convince health care providers that taking an occupational/environmental medicine history will help them to fulfill the SH requirement for billing for a comprehensive visit, particularly for new patients. The billing codes affected are: New outpatient visit codes and New outpatient consults and New inpatient consults and Initial hospital care and Emergency department These HCFA Documentation Guidelines apply only to Medicare patients; however, most third-party payers have adopted the same guidelines for their reimbursement schedules. Considerable research will need to be done to determine if this approach is viable. PRACTICE Activity #5 Require pesticide poisoning reporting for worker compensation reimbursement and automatic worker compensation reimbursement for work-up of suspected occupational pesticide 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 health effects for worker compensation reimbursement; and standardized weight-of-evidence for claims reimbursement for pesticide-related illnesses. Tasks include: Target high-priority states for change. Gather information about model state worker compensation laws (especially California and Washington). Win support of professional organizations, advocacy groups, and state agencies. 81

90 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 Department of Health (DOH) both have responsibilities for addressing chemically-related illnesses (CRI) illnesses known or suspected to be caused or substantially worsened by exposure to chemicals in the workplace or other environments. PRACTICE WASHINGTON STATE S CLAIMS PROCESS To increase efficiency and provide more consistent handling of chemically-related claims, L&I established a single CRI unit with responsibility for all chemicallyrelated claims. Claims adjudicators in the CRI unit receive special training on chemically-related injuries and illnesses. L&I has also contracted with an occupational medicine physician to provide additional medical review of the more complex 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: An injury/illness incident is eligible for a claim to be filed whenever medical treatment is provided. 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 if it is determined not to be work-related, the initial visit(s) and testing are paid for. Individuals with accepted claims are eligible for time loss (wage replacement) if they lose more than 3 days of work. Health care providers are required to file a claim if the worker feels the condition is 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 specific exposure event. The goals include early intervention to reduce exposures and prevent future morbidity and mortality. For example, a cluster of carbon monoxide poisonings was identified, triggering efforts to reduce future exposures in the plant where the poisonings occurred. CRI staff find this process also improves the adjudication of claims by grouping together the claims from a particular employer. Since 1990, DOH has been responsible for investigating pesticide-related illness incidents and developing a database of pesticide-related problems. L&I provides detailed reports to DOH to enable DOH to include worker compensation claims in their investigations. Some consider the claims process to fulfill their reporting requirements, although there is a longer delay when L&I reports claims to DOH than when a health care provider reports directly to DOH at the time a patient is evaluated. It is not clear if this mechanism is sufficient or could be improved. Source: Mary Miller, Washington State Department of Labor and Industries 82

91 Approach state Workers Compensation Commissions for changes. Build key leadership supporters including worker compensation attorneys, labor, farmworker groups, clinicians, and public health groups. Address barriers such as lack of leadership, cost, and decentralized state authorities. Activity #6 Promote documentation of occupational and environmental history in medical records, via incorporation into quality assurance/quality control mechanisms. Quality Assurance/Quality Control mechanisms could also be used to promote documentation that providers have given pesticide information to certain at-risk groups (e.g., parents of toddlers, farmworkers, pregnant women). Activities include: Create respected consensus on minimum necessary documentation through a committee process. Research the scope, authority, and current priorities of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Approach the JCAHO to require documentation of Occupational and Environmental Medicine (OEM) history and pesticide education. Approach targeted major managed care organizations to require documentation of OEM history and pesticide education. Approach family medicine and Ob/Gyn to include Occupational and Environmental Medicine history and pesticide education in their chart-review for certification/ recertification. Determine whether this is a priority activity area, and address barriers such as institutional inertia, extra burden on hospitals, clinics, and JCAHO, and time pressure. PRACTICE Stakeholders Federal agencies and foundations that support research and interventions Professional associations NIOSH Educational Resource Centers Health care centers and hospitals Community clinics 83

92 Evaluation of Outcomes/Indicators of Success PRACTICE Increase in number of grants and level of support available to practicing primary care providers. Increase in publications of research findings and interventions undertaken by providers. Report on success stories and lessons learned in the field. Adoption of models in other settings. Increase in number of continuing education offerings. Increase in number of people attending continuing education programs and number of people completing Web-based credits (percentage increase in participation each year). Short-term and long term changes in Evaluation and Management coding and worker compensation. Questions added to recertification exams of professionals. Worker compensation systems in target states are changed to reimburse for work-up of suspected pesticide poisoning, and payment is linked to reporting of pesticide exposures to state registries. Quality Assurance/Quality Control mechanisms in targeted health care organizations are changed to incorporate review of documentation of an occupational and environmental history. Background One of the most effective ways to bring about change is to build incentives into existing requirements and activities of health care plans and practitioners. There are certain key points of entry into the health care system that require providers to address specific issues in their practices. For example, by integrating pesticide components into worker compensation, E&M coding, and quality assurance, the initiative can ensure that pesticide issues will become institutionalized into health care practice. 84

93 Resources and Tools Resources of all kinds serve as the infrastructure for this initiative. The five resource components are designed to identify, create, and disseminate the necessary tools to support change in both educational and practice settings. Key concerns are to avoid duplication of existing resources by inventorying the current stock of resources available, and to ensure the scientific credibility and usefulness of resources by establishing a national review board to evaluate them. Component A: Inventory existing resources Determine what educational and informational programs and materials for health care providers currently exist in education and practice settings and what gaps should be filled. Component B: Establish a national review board Create a national body to determine assessment criteria and evaluate existing resources, with the goal of identifying, selecting, and assessing the ideal resources that primary health care providers use in both educational and practice settings for prevention, diagnosis, treatment, and referral of pesticide-related health conditions. Component C: Create an information gateway Establish a print, telephone, and Webbased gateway through which primary health care providers can access information and educational resources. Component D: Develop teaching/learning resources for educational settings Identify and develop new content resources, tools, and methods for faculty in educational settings. Component E: Develop new resources for practice settings Identify and develop new content resources, tools, and methods for health care providers in practice settings. RESOURCES 85

94 RESOURCE COMPONENT A: Inventory Existing Resources Statement Determine what educational and informational programs and materials for health care providers exist in education and practice settings and what gaps should be filled. Expected Outcomes An inventory of pesticide resources based upon information from health care providers in education and practice settings. Target Audience Readiness for Change: This strategy will target health care providers who have already developed model tools, resources, and programs so as to create a centralized inventory of what exists and what gaps need to be filled. Proposed Activities Activity #1 Develop and document the inventory methodology to be used in collecting resources, including documentation for the survey instrument and an announcement requesting resources and materials, including placing a solicitation in the Federal Register. Activity #2 Conduct the resources inventory. Key questions to be asked of organizations in the survey include: RESOURCES What resources do you use to diagnosis pesticide exposures? What resources do you use to treat pesticide exposures? What resources do you use to refer pesticide-exposed patients? How useful are current resources? At what stage of change is the resource targeting providers? For which target discipline is the resource designed? For what practice settings is the resource designed? 86

95 For what characteristics of patient/community populations are the resources designed? What resources are needed that are not readily available? Stakeholders Federal Interagency Planning Committee for this initiative Organization conducting the inventory Evaluation of Outcomes/Indicators of Success Inventory completed and available. Feedback from Website users indicating additional resources and/or identifying gaps. Acknowledgment of a thorough inventory by the national review board. Background In order to evaluate the existing resources and to effectively disseminate what is available, an inventory of available resources needs to be created. Such an inventory is already underway and will be completed as part of this initiative. The inventory will be available online and in print formats. RESOURCES 87

96 RESOURCE COMPONENT B: Establish National Review Board to Evaluate Resources Statement Create a national body to determine assessment criteria and evaluate existing resources, with the goal of identifying, selecting, and assessing the ideal resources that primary health care providers use in both educational and practice settings for prevention, diagnosis, treatment, and referral of pesticide-related health conditions. Expected Outcomes An established board available for ongoing consultation and review. A published document with a list of evaluated and recommended pesticide resources that primary health care providers can use in both educational and practice settings for prevention, diagnosis, treatment, and referral of pesticide exposures. Proposed Activities RESOURCES Establish selection criteria for review board membership. Establish a multidisciplinary national review board to conduct the evaluation of existing resources. Refine the list of suggested evaluation criteria: Pilot tested Demonstrated level of success Regional applicability Significant number of participants Cost-effectiveness Peer review of resources Significant relevance Related to at least one competency/practice behavior Developed by credentialed sources/authors Accessibility 88

97 Credibility of information/sound science Convenience Endorsement by appropriate professional association Approved programs for CE credits Built-in incentives to use the resources. Convene the national review board to evaluate the existing inventory of resources (Resource Component A) using the evaluation process. Publish recommended resource document online and as a paper document. Assess the usefulness of the resource document to health care providers. Stakeholders Federal Interagency Planning Committee National review board members Evaluation of Outcomes/Indicators of Success Published document of resources, online and as a paper document. Feedback from health care providers on the usefulness of the resource list (via online mechanism and mail-back card inserted in the paper document). Background The concept of a national review board came out of the Resources Workgroup s focus on how pesticide-related resources used in education and practice settings could be evaluated, in the interests of using the highest quality materials. The review board would be composed of leaders in the areas of pesticides and primary health care. RESOURCES 89

98 RESOURCE COMPONENT C: Create an Information Gateway Statement Establish a print, telephone, and Web-based gateway through which primary health care providers can access information and educational resources. Expected Outcomes A fully functional, interactive, informational gateway that provides primary health care providers with access to readily available and useful pesticide resources. Target Audience Readiness to Change, Maintenance: This component targets individuals and organizations who are looking for models and resources for how to address health effects from pesticide poisonings, as well as individuals and organizations who have become part of the cadre of health care providers involved in this issue. RESOURCES Proposed Activities Activity #1 Build the gateway using resources gathered through the inventory process and evaluated by review board. Identify existing resource centers that could develop the gateway, under direction of the Federal Interagency Planning Committee. Develop or enhance a resource center infrastructure and address logistical issues including a toll-free number and Website functioning in real time. Assign priority access to primary health care providers. Link to regional and geographical specific information, coordinated industry Websites, and other resources, universities, associations, etc. Activity #2 Market the gateway and its information/education resources through dissemination channels to reach primary health care providers in education and practice settings. 90

99 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, why primary care providers should be concerned, and how to access the gateway. To provide tools/resources to health care providers ready to make changes: Disseminate curricular packages to educational settings and training packages to practice settings. Packages may be defined as lectures, slides, case studies, exercises, assignments/project ideas, ideas on how to involve experts, access to gateway, etc. Packages would be combined from existing resources and/or new resources that have undergone peer-review and pilot testing. To help health care providers learn of the latest resources: Disseminate concise information on how to access the gateway, especially the network of expertise. Dissemination methods include posters, flyers at conferences, NPTN clearinghouse, and links on Websites. Convene one or more focus groups to evaluate the effectiveness of the dissemination efforts. Stakeholders Federal Interagency Planning Committee Organization to manage the gateway Evaluation of Outcomes/Indicators of Success Number of requests for information. Number of hits to the Website. Number of calls. Customer satisfaction survey on the Website. Feedback from focus groups. Degree to which the dissemination efforts are nationwide. Degree to which dissemination efforts and resources address primary health care providers at varying stages of change. Background A centralized gateway to the wealth of information available and paths to information can be an efficient way to provide comprehensive access to evaluated, pesticide-related resources. This centralized resource should include emergency information and contacts, educational RESOURCES 91

100 materials, and other resources, and be accessible by an 800 number and via a Website. The gateway must be able to provide real-time answers to short-term questions as well as larger educational resources. Access must be multi-pronged: phone, Web, print, /listservs. It should contain geographic linkages to local providers, researchers, and sources of local information (e.g., local health departments). The gateway will build on existing resource networks, such as NPTN (see box below) and will require a multi-stakeholder partnership for effective implementation. Clearly, the gateway itself will need extensive marketing in order to ensure that it is widely used. RESOURCES NATIONAL PESTICIDE TELECOMMUNICATIONS NETWORK A cooperative effort between Oregon State University and EPA, NPTN provides objective, science-based, and plain-language pesticide information to the general public, and medical and veterinary communities. It handles over 23,000 calls a year on topics ranging from toxicology to pesticide poisonings. NPTN s staff of pesticide professionals includes toxicologists and a physician trained to: help callers interpret and understand health and environmental information about pesticides answer questions about pesticide labels supply general information on the regulation of pesticides in the United States access over 300 pesticide resources direct callers for pesticide incident investigation, emergency human and animal treatment, safety practices, clean-up and disposal, laboratory analyses confer with private physicians to determine an appropriate treatment plan in the event of poisonings provide information regarding safety practices for field/farm workers and handlers provide callers with information about anti-microbial pesticides ( ) (Monday-Friday). Toll-free tel: daily, 6:30 a.m. - 4:30 p.m. (Pacific time); Fax: ; nptn@ace.orst.edu; Website: 92

101 RESOURCE COMPONENT D: Develop Teaching/Learning Resources for Educational Settings Statement Identify and develop new content resources, tools, and methods for faculty to use in educational settings. Expected Outcomes Teaching modules Network of experts and organizations nationwide Target Audience Readiness to Change: This component targets faculty in educational settings who are ready to integrate the issue into their curriculum. Proposed Activities Create teaching modules for faculty that address pesticides/environmental health and that respond to the recommended competencies, the National Guidelines, and the assessment of educational institutions. Review existing teaching modules collected and evaluated by the national review board and review the assessment of educational institutions to determine the type of teaching modules still needed by faculty. Identify key experts and/or organizations to develop teaching modules and create contractual agreements for the development of specific modules. Develop pesticide-teaching modules with flexibility for use by different schools, departments, etc. Establish a peer review and pilot testing process for the modules developed. Distribute teaching modules to all academic health centers and nursing schools. Make modules available online (via gateway and/or published resources document). RESOURCES 93

102 Stakeholders Faculty who have already developed resources Key professional associations for faculty Cooperative Extension Pesticide Safety Educators State Lead Agency Pesticide Educators Evaluation of Outcomes/Indicators of Success New resources are approved and endorsed by the national review board. Background Guiding principles for developing new resources include: Easy to implement Interdisciplinary Culturally and geographically relevant Measurable outcomes Usable in both urban and rural communities. RESOURCES 94

103 RESOURCE COMPONENT E: Develop New Resources for Practice Settings Statement Identify and develop new content resources, tools, and methods for health care providers in practice settings. Expected Outcomes Increased access to and availability of relevant information and resources including experts in the field, content materials and available data within communities. Target Audience Readiness to Change: This component targets practitioners who are ready to integrate the issue into their clinical practice and prevention activities. Proposed Activities Activity #1 Develop a variety of resources, including: 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, covering the breadth of topics related to pesticides. User-friendly materials: 1. Pocket guides for physicians and nurses, for both print and Web media. Ensure that guides are dated so that revisions can be made and distributed, and that they contain return cards for new information and comments. Guide I: Highlights of symptoms, treatments, and reference (similar to Highlights feature in Recognition and Management of Pesticide Poisoning) Guide II: How to take an environmental history (could be adapted from Recognition manual). 2. ABCs of environmental health a simple tool, similar to the CAGE screening tool for 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. RESOURCES 95

104 Outreach: Use of radio for both patients and primary care providers from Central and Latin American countries. Certification of training: Some type of recognition that a primary care provider has completed a certain level of training. Journal articles in the literature: Encourage researchers to produce professional journal articles on the subject of pesticide-related health concerns. Internet/Web-based materials and training, including video-conferencing, satellite training. Encourage creation of a centralized industry Website on pesticide/health data. Activity #2 Increase the participation of professional associations in the support, use, and promotion of educational materials and resources. Develop model policy statement that can be tailored and adopted by professional associations. Coordinate with national organizations to develop policy statements on educating health care providers about pesticides (along the lines of those developed by the American Academy of Pediatrics). Encourage development of environmental health committees in professional organizations and local chapters. Coordinate with professional associations to secure more continuing medical education (CME) opportunities at national and regional meetings. Build pesticide/environmental health CME into Internet-based offerings by professional associations. Activity #3 Establish a national network of experts and organizations that can answer questions and serve as resources to health care providers nationwide. RESOURCES Identify existing organizations that have the capability to establish and/or expand a database of individuals and organizations. Identify areas of expertise to be included. Identify experienced professionals and define the parameters of their responsibility. Solicit availability for consultation, teaching, guidance, etc. Develop a Pesticide Poisoning Orientation Training program to build practice champions or motivate providers to become champions. Training could be Web-based, via audio 96

105 cassettes, CDs, or in-person. Short courses (half or full day) could be held in conjunction with other professional conferences, and should be integrated with other disciplines. Stakeholders Faculty who have already developed resources Key professional associations for faculty Cooperative Extension Pesticide Safety Educators State Lead Agency Pesticide Educators Network of pesticide and pest management experts in land grant colleges and universities throughout the U.S. Evaluation of Outcomes/Indicators of Success Increased utilization of community resources. Increased number of customized educational programs/materials. Increased number of collaborations among resources. Number of RFPs related to new and innovative ways to get information to primary care providers. Increased number and frequency of pesticide-practice related publications. Increased number of CME courses. Increased number of presentations in practice settings. Numbers of policy statements. Numbers of re-certification exams. Numbers of questions on exams. Increased availability of reimbursement mechanisms. Number of people applying for Certificate of Recognition. Number of requests made of experienced professionals. Number of professionals who agree to participate. Diversity of professional background. RESOURCES 97

106 Background A 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, Webbased instruction (depending on how recently the providers graduated and how comfortable they are with technology). Providers are overburdened and need quick help either in the form 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 literature and to the extent that there is a sufficient stream of articles in the literature on pesticide diagnosis and treatment, it can be expected that providers will encounter pesticide-related information in the course of their reading. However, there may well be a gap in articles on pesticide poisoning prevention and diagnosis in the journals that are generally read, a gap that could be remedied by encouraging researchers to prepare and submit such articles. 98

107 Conclusion This Implementation Plan is the starting point for a strategic and coordinated effort to change our national health care system so that it adequately addresses the problems posed 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 the recognition, management and prevention of pesticide-related health conditions. At the heart of the Plan is a three-pronged strategy for accomplishing the necessary change. The strategy is aimed at improving the teaching of pesticides and environmental health in educational settings of nursing, medical, and other health professional schools, changing the way primary care providers assess and react to pesticide cases in their practice settings, and creating the necessary new resources for both educational and practice settings that build upon the existing knowledge 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 other toxic exposures and broader efforts to educate health care providers about environmental health problems. It is hoped that this Plan will pave the way for the strategic next steps needed to move forward a common national vision for environmental health awareness, education and training for health care providers. Work is already underway on a number of components of the Plan including development of competency guidelines, establishment of a national evaluation panel/review board, conducting an audience assessment through literature review and focus groups, and creation of an information gateway. Most of the remaining components will get underway in the next three 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 of a wide spectrum of stakeholders nationwide. This Implementation Plan can be used as a way of introducing new additional stakeholders and interested parties to the initiative and of involving them in specific components. The Plan will also form the basis for a National Forum to be convened in As work proceeds, workgroup members and other stakeholders are encouraged to stay active in the initiative through and EPA s host Website ( healthcare) and to bring the initiative to the attention of colleagues and other contacts in the health care world. 99

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109 References Adami, H.O. et al., Organochlorine compounds and estrogen-related cancer in women. Cancer Causes and Control, 6: Ahlborg, U.G., L. Lipworth, L. Titus-Ernstoff, et al., Organochlorine compounds in relation to breast cancer, endometrial cancer, and endometriosis: An assessment of the biological and epidemiological evidence. Critical Reviews in Toxicology, 25: Alavanja, M.C.R, D.P. Sandler, S.B. McMaster, et al., The Agricultural Health Study. Environmental Health Perspectives, 104: American Association of Poison Control Centers (AAPCC), Tabulations prepared for EPA: All Pesticides Without Concomitant Exposures. Washington, D.C., December. American Medical Association, Report 4 of the Council on Scientific Affairs, Educational and Informational Strategies for Reducing Pesticide Risks (Resolutions 403 and 404), December. Blondell, J., Epidemiology of pesticide poisonings in the U.S., with special reference to occupational cases. Occupational Medicine: State of the Art Reviews,Vol April-June. Centers for Disease Control and Prevention (CDC), Organophosphate insecticide poisoning among siblings Mississippi. MMWR. 33:592. Centers for Disease Control and Prevention, 1999a. Aldicarb as a cause of food poisoning Louisiana, MMWR. 48: Centers for Disease Control and Prevention, 1999b. Surveillance for pesticide-related illness during the Medfly Eradication Program in Florida, MMWR. 48: , Chafee-Bahamon, C., D.L. Caplan, and F.H. Lovejoy, Patterns in hospital s use of a regional Poison Information Center. American Journal of Public Health, 73: Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment, Organophosphates. Department of Health, United Kingdom. Crown Copyright: London. Davis, D.L., H.L. Bradlow, M. Wolff, et al., Medical hypothesis: Xenoestrogens as preventable causes of breast cancer. Environmental Health Perspectives, 101:

110 Environews, Methyl Parathion Comes Inside. Environmental Health Perspectives, 106(7), July. Eubanks, M.W., Hormones and health. Environmental Health Perspectives, 105: Harchelroad, F., R.F. Clark, B. Dean, and E.P. Krenzelok, Treated vs. reported toxic exposures: Discrepancies between a Poison Control Center and a member hospital. Veterinary and Human Toxicology, 32: Hoar, S.K., et al., Agricultural herbicide use and risk of lymphoma and soft tissue sarcoma. JAMA, 256: Institute of Medicine, Role of the Primary Care Physician in Occupational and Environmental Medicine, IOM Report, Division of Health Promotion and Disease Prevention, National Academy Press, Washington, D.C. Keifer, M.C. and R.K. Mahurin, Chronic neurologic effects of pesticide overexposure. Occupational Medicine: State of the Art Reviews, 12(2): Levy, B.S., The teaching of occupational health in US medical schools: Five-year followup of an initial survey. American Journal of Public Health, 75: Litovitz, T.L., M. Smilkstein, L. Felberg, et al., Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. American Journal of Emergency Medicine, 15: McCaig, L.F. and C.W. Burt, Poisoning-related visits to emergency departments in the United States, Clinical Toxicology, 37: McCaig, L.F., National Center for Health Statistics. Personal communication to Jerome Blondell, Feb. 7. National Center for Environment Health (NCEH), NCEH Activities during Lorain County Methyl Parathion Decontamination Project. Centers for Disease Control and Prevention. Peters, H.A., W.A. Croft, E.A. Woolson, et al., Arsenic, chromium, and copper poisoning from burning treated wood (Letter to the Editor). New England Journal of Medicine, 308:

111 Pope, A.M. and D.P. Rall, eds., Environmental Medicine: Integrating a Missing Element into 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., 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, Changing for Good: The Revolutionary Program That Explains the Six Stages of Change and Teaches You How to Free Yourself from Bad Habits. Avon Books (pb). Reigart, J.R. and J.R. Roberts, Recognition and Management of Pesticide Poisonings, fifth edition. EPA#735-R , Washington, DC. Robinson, J.C., W.S. Pease, D.S. Albright, and R.A. Morello-Frosch, Pesticides in the Home and Community: Health Risks and Policy Alternatives. CPS Report, California Policy Seminar, Berkeley, CA. Rosenstock, L., M. Keifer, W.E. Daniell, et al., Chronic central nervous system effects of acute organophosphate pesticide intoxication. Lancet, 338: Savage, E.P., T.J. Keefe, L.M. Mounce, et al., Chronic neurological sequelae of acute organophosphate pesticide poisoning. Archives of Environmental Health, 43: Schenk, M., S.M. Popp, A.V. Neale, and R.Y. Demers, Environmental medicine content in medical school curricula. Academic Medicine, Vol. 71, No. 5, May. Schnitzer, P.G. and J. Shannon, Development of a surveillance program for occupational pesticide poisoning: Lessons learned and future directions. Public Health Report, May-Jun; 114(3): Sever, L.E., T.E. Arbuckle, and A. Sweeney, Reproductive and developmental effects of occupational pesticide exposure: The epidemiologic evidence. Occupational Medicine: State of the Art Reviews, 12(2): Slovic, P., B. Fischhoff, and S. Lichtenstein, "Facts and fears: Understanding perceived risk." In: Schwing, R.C. and W.A. Albers, Jr. eds., Societal Risk Assessment: How Safe is Safe Enough? New York, Plenum Press. 103

112 Steenland, K., B. Jenkins, R.G. Ames, et al., Chronic neurological sequelae to organophosphate pesticide poisoning. American Journal of Public Health, 84: Stephens, R., A. Spurgeon, I.A. Calvert, et al., Neuropsychological effects of long-term exposure to organophosphates in sheep dip. Lancet, 345: U.S. EPA, 1998a. Office of Pesticide Programs Annual Report for FY Office of Prevention, Pesticides, and Toxic Substances, EPA #735-R , January. U.S. EPA, 1998b. Pesticides and National Strategies for Health Care Providers; Workshop Proceedings. Office of Prevention, Pesticides, and Toxic Substances, EPA #735-R , July. U.S. EPA, Pesticides Industry Sales and Usage: 1996 and 1997 Market Estimates. Office of Prevention, Pesticides, and Toxic Substances, EPA #733-R , Washington, D.C. U.S. General Accounting Office, Pesticides on Farms: Limited capability exists to monitor occupational illnesses and injuries. (GAO/PEMB-94-6) Washington, D.C., December. Veltri, J.C., N.E. McElwee, and M.C. Schumacher, Interpretation and uses of data collected in Poison Control Centers in the United States. Medical Toxicology, 2: Whitmore, R.W., J.E. Kelly, and P.L. Reading, National Home and Garden Pesticide Survey: Final Report, Volume 1, Research Triangle Institute NC: RTI\ F, Research Triangle Park, NC. Whorton et al., Testicular function in DBCP exposed workers. Journal of Occupational Medicine, 21: Wigle, D.T., R.M. Semenciw, K. Wilkins, et al., Mortality study of Canadian male farm operators: Non-Hodgkin s lymphoma mortality and agricultural practices in Saskatchewan. Journal of National Cancer Institute, 82: Zahm, S.H., D.D. Weisenburger, P. Babbitt, et al, A case-control study of non-hodgkin s lymphoma and the herbicide 2,4-dichlorophenoxyacetic acid (2,4-D) in eastern Nebraska. Epidemiology, 1: Zahm, S.H., M.H. Ward, and A. Blair, Pesticides and Cancer. Occupational Medicine: State of the Art Reviews, 12(2): Zweiner, R.J. and C.M. Ginsburg, Organophosphate and carbamate poisoning in infants and children. Pediatrics, 81:

113 Glossary AAP AACN AAFP AAMC ACNM AAOHN ACOEM AMA ANA APN ATSDR CDC CE CME CNS E&M EPA FNP GNP HHS HRSA NEETF NIEHS NIH NIOSH American Academy of Pediatrics American Association of Colleges of Nursing American Academy of Family Physicians Association of American Medical Colleges American College of Nurse Midwives American Association of Occupational Health Nurses American College of Occupational and Environmental Medicine American Medical Assocation American Nurses Association Advanced Practice Nurse Agency for Toxic Substances and Disease Registry Centers for Disease Control and Prevention Continuing education Continuing medical education Clinical nurse specialist Evaluation and Management Environmental Protection Agency Family Nurse Practitioner General Nurse Practitioner Department of Health and Human Services Health Resources and Services Administration The National Environmental Education & Training Foundation National Institute for Environmental Health Sciences National Institutes of Health National Institute for Occupational Safety and Health 105

114 NLN NPTN OSHA PNP RFA RFP USDA National League of Nursing National Pesticides Telecommunications Network Occupational Safety and Health Administration Pediatric Nurse Practitioner Request for Applications Request for Proposals U.S. Department of Agriculture 106

115 Appendix A: Expert Panel Proceedings To launch the Pesticides and National Strategies for Health Care Providers initiative, EPA and several other federal agencies convened an expert forum to begin the process of developing 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 Health and Human Services, Department of Agriculture, and Department of Labor. The Association of Teachers of Preventive Medicine and The National Environmental Education and Training Foundation 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 health organizations, open to the public, and with comments and questions from federal agencies and outside observers. The panel included representatives from: American Academy of Family Physicians, 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 and Environmental Medicine, American Nurses Association, Council of State and Territorial Epidemiologists, Migrant Clinicians Network, National Center for Farmworker Health, National Organization of Nurse Practitioner Faculties, National Pesticide Telecommunications Network, National Rural Health Association, Pennsylvania State University/National Agromedicine Consortium, and Suncoast Community Health Centers. Concerns About Provider Education and Training The 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 of their education about pesticide exposure. The panel also recognized that the lack of training is larger than just pesticides and reflects a serious deficiency in education on environmental and occupational health. The panel briefly summarized the main concerns in provider knowledge about pesticide exposures: Pesticide exposures are often underreported. 107

116 Providers often do not know how and where to report pesticide exposures; sometimes the reporting is considered burdensome given their demanding work environments. Health conditions associated with pesticide exposures are often misdiagnosed. Providers do not often see acute pesticide poisoning, and they do not possess enough knowledge to recognize chronic cases. Providers have not received training on pesticide exposures during their years of formal education. Pesticide exposures and associated health conditions are difficult topics to teach because they require additional knowledge on toxicology and other topics which are often not included in the curriculum of health professional education. Expected Outcomes for Primary Care Providers The panel discussed at length what should be expected of primary care providers. Agreement was reached that all primary care providers should: Be knowledgeable about pesticides and recognize pesticide exposures as a health concern. Be able to diagnose and treat pesticide exposures at the earliest possible time and complete the appropriate follow-up and referral (exposure management). Take preventive measures in both the clinical and community settings, including anticipatory guidance and community education (prevention management). Report exposures and health outcomes of either patients or communities. Access the appropriate resources/specialists (local, regional, and national). Expert Panel s Overarching Strategies The expert panel generated specific strategies that were consolidated into four general topic areas: 1. Define and recommend basic environmental health (emphasizing pesticides) competencies for primary care providers. 2. Develop a set of education and training strategies for students and primary care providers on the subject of pesticide-related health concerns. 3. Raise the awareness of primary care providers on pesticide issues and risk factors through professional meetings, informational mailings by professional associations, and journal articles. 4. Centralize information resources for primary care providers and strengthen their linkage to existing resources. The panel recommended that three workgroups be created to develop strategies on education, practices, and resources. 108

117 Expert Panel Membership Joni Berardino, MS, LSW National Center for Farmworker Health Candace M. Burns, PhD, ARNP National Organization of Nurse Practitioner Faculties, and University of South Florida College of Nursing Joe Fedoruk, MD, DABT, CIH American College of Occupational and Environmental Medicine J. Ward Donovan, Jr., MD, FACEP American College of Emergency Physicians, and Pennsylvania University Poison Center, Milton S. Hershey Medical Center Rugh Henderson, MD, MPH North American Agromedicine Consortium, Pennsylvania Agromedicine Program, and Penn State University College of Medicine Michael Hodgman, MD National Rural Health Association, and Bassett Healthcare/NY Center for Agricultural Medicine and Health Andrea R. Lindell, DNSc, RN American Association of Colleges of Nursing, and University of Cincinnati College of Nursing Mary Miller, MN, ARNP American Nurses Association, and Washington State Department of Labor and Industries Karen Mountain, MBA, MSN, RN Migrant Clinicians Network Dennis Penzell, DO, FACP Suncoast Community Health Centers, Inc. George C. Rodgers, Jr., MD, PhD American Association of Poison Control Centers, and University of Louisville School of Medicine 109

118 Jackilen Shannon, PhD Council of State and Territorial Epidemiologists, and Texas Department of Health Elisabeth Spector, MD, MPH American Academy of Family Physicians Roger F. Suchyta, MD American Academy of Pediatrics Greg P. Thomas, PA-C American Academy of Physician Assistants Sheldon Wagner, MD National Pesticide Telecommunications Network, and Oregon State University Speakers and Facilitator Wilson Augustave Finger Lakes Migrant Health Care Project Louise M. Rauckhorst, EdD, MSN Philip Y. Hahn School of Nursing, University of San Diego Mark G. Robson, PhD, MPH Environmental and Occupational Health Sciences Institute, and Rutgers University Susan T. West, MPH, Facilitator The National Environmental Education and Training Foundation, Inc. 110

119 Appendix B: Summary Proceedings from Workgroups This appendix provides a brief summary of the deliberations of the three workgroups created under this initiative and a list of their members. The strategies and plans that emerged from the workgroup meetings are the subject of this Implementation Plan. The workgroups discussed competencies and expected outcomes, and devoted some time to brainstorming sessions on overall strategies and plans of action. Members held small group discussions for the better part of the second day of each meeting, to flesh out the strategies and action items. The groups then reviewed the strategies and decided on next steps. Both short-term (1-3 year timeframe) and longer-term actions (3-5 years) were identified. The meetings were facilitated by Susan West of The National Environmental Education and Training Foundation (NEETF). The Education Workgroup was charged with developing a national strategic plan to enable undergraduate and graduate formal education and training institutions to prepare primary care providers to prevent, diagnose, treat, and refer patients exposed to pesticides. The workgroup was expected to set (and/or select already established) competencies for the educational setting, and to identify strategies on how to achieve those competencies through education, training, and raising student awareness. The Practice Workgroup was charged with developing a national strategic plan for improving the practice of primary care providers in preventing, diagnosing, treating, and referring patients exposed 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 those competencies through education, training, and raising awareness. The Resources Workgroup was charged with developing a national strategic plan which addresses an effective method of linking, centralizing, and/or disseminating an array of resources 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 to develop needed resources for health care providers. 111

120 Key Principles Key principles and findings emerging from the three 1999 workgroups include: Pesticides must be seen in the context of environmental and occupational health. All three workgroups expressed the opinion that pesticides are a useful and important focus of attention in themselves; however, pesticides must also be seen as a steppingstone for the underrecognized and broader issue of environmental and occupational health as a whole. Gaining attention and raising awareness are the primary challenges. One of the most difficult obstacles is simply gaining the attention of students, faculty, and primary care providers 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 case encounter can have long-lasting effects. Much of the effort of the workgroups was driven by the need to gain attention and raise awareness. Strategies include developing case statements, creating monetary and professional incentives, nurturing pesticide/ environmental health champions and model practices and convening focus groups to better understand providers communication styles. Environmental histories are gateways. Few primary care providers ask patients the questions that would be likely to alert them to the possibility of a pesticide-related illness. Although it is important for primary care providers to take environmental histories, both workgroups recognized that a full environmental history can sometimes take up the entire patient visit. However, getting primary care providers to ask just a few simple questions such as Where do you work? and Do you think your problems are related to something that happened at work or at home? could go a long way toward uncovering pesticide-related health conditions and raising awareness about the environment in which patients live. There is a spectrum of pesticide-related health conditions. Stereotypes of pesticide illness insecticides, farmworkers, acute poisoning, cholinesterase testing may cover an 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 wide spectrum of pesticide-related health concerns: low-dose chronic effects as well as acute, high-dose poisonings; effects on children, people with chemical sensitivities, other vulnerable populations; the wide variety of pesticide products on the market; urban, rural, and suburban settings. The need is for credible, convenient, and easy-to-use resources. The best way to reach already overburdened primary care providers is by ensuring that the resources available to them on pesticide-related illnesses are scientifically credible, easy to access, and provide quick answers to providers questions. 112

121 The importance of understanding the audience cannot be overstated. Primary care providers work in a wide variety of settings and have varying levels of exposure to pesticiderelated health issues. Understanding primary care providers their backgrounds, level of awareness and knowledge about pesticide issues, and preferred modes of receiving information is essential to effectively targeting and reaching the audience for this initiative. Evaluation plays a key role. There is a strong need for expert evaluation of the resources currently available to primary care providers on pesticide topics and for ensuring that new materials developed through this initiative meet stringent evaluation criteria. 113

122 Education Workgroup One of the key issues that workgroup members grappled with over the course of the meeting is the need to gain the attention of health care students, faculty, and primary care 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 curriculum for pesticide and environmental health material. It would be unreasonable to expect more than a total of hours over the course of a four-year degree program; a more modest rise to just 10 hours of instruction would stand a better chance of acceptance. The key is to get the education setting both interested in and comfortable with pesticide issues. Making the Case Workgroup members agreed on the need to make the case to medical and nursing schools about the importance of environmental health education and 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 the breadth of the problem of pesticide-related health concerns. Even the most supportive faculty challenge why environmental health is important to teach. Workgroup members spent considerable time discussing how to spark the interest of faculty and students. One workgroup member noted that environmental poisonings are seldom encountered by medical school students. The best way he has found to motivate medical students is to have them accompany primary care physicians in rural area practices so that they can experience the scope of occupational medicine first-hand. The payoff is that students value this practical type of learning enormously, and that it has a greater impact than hearing lecture after lecture on the same topic. It also combats 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 their curriculum, and how can the materials be designed to make it easy for them to let us in? It is important to identify where in the curriculum the materials should be inserted. Usually the schools have a flow of courses/topics and the group could suggest where a given topic in environmental health would fit. The aim of this initiative is not to overwhelm medical and nursing students with a vast amount of information. Developing some tools along the lines of the successful 10 Steps to Identify Cancer would be a useful approach. 114

123 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 many faculty 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 medical faculty may lack the toxicology background. Others agreed that it might be difficult to find enough faculty with competence in pesticides/environmental health (environmental health). Workgroup members discussed at some length whether faculty should be trained to become comfortable with, or expert at, teaching pesticides/environmental health subjects, or whether it is sufficient for faculty 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 will use it. The situations where new material has worked best in medical schools is where there was an advocate or champion who pushed until the material was included in the curriculum. A study at the Worcester School of Nursing reported that the number one barrier to integrating environmental 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 funding of environmental health positions, which provided half of the faculty s salary plus evaluation components, and the faculty development grant program at the University of South Florida that supported curriculum development and research in substance abuse. Faculty spent the first two of the five years in becoming experts in their chosen areas through seminars, courses, networking with other experts, etc. Workgroup members discussed the fragile toehold that environmental health courses currently have in health care education. There is no additional funding for teaching pesticides/ environmental health courses and environmental health is not a revenue-generator. This may 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, possibly 20 are on the verge of disappearing. The workgroup discussed the possibility of developing fellowships 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-house faculty to incorporate existing resources and information into an institution s curriculum. Convincing the Examination Boards One way to motivate change in curriculum, workgroup members agreed, is to convince the medical and nursing examination boards of the importance of environmental health in the coming years, and push them to incorporate environmental health questions on their exams. 115

124 This would also be one of the better ways to institutionalize the subject matter over the long term. Workgroup members felt that some of the boards would be receptive to a concerted effort in this area. For example, the Residency Review Committee for Pediatrics in 1996 adopted two recommendations on children s environmental health. The workgroup discussed whether public education and K-12 education should also be dealt with as part of this initiative. The group noted efforts on environmental education becoming incorporated into K-12 education, partly through the support of EPA and the National Institute of Environmental Health and Sciences. But while many K-12 schools are teaching ecological effects, 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 students entering 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 focuses on educating primary care providers. The group recommended that the issue be addressed in other ongoing initiatives. 116

125 Education Workgroup Membership Co-Chairs Andrea Lindell, DNSc, RN American Association of Colleges of Nursing, and University of Cincinnati, College of Nursing Ameesha Mehta, MPH Office of Pesticide Programs U.S. Environmental Protection Agency Facilitator Susan West, MPH The National Environmental Education and Training Foundation, Inc. Members Amy Brown, PhD American Association of Pesticide Safety Educators, and University of Maryland-College Park Candace Burns, PhD, ARNP National Organization of Nurse Practitioner Faculties, and University of South Florida Joan Spyker Cranmer, PhD University of Arkansas Medical School Miriam Cruz Equity Research Kesner Flores, EMT Cortina Indian Rancheria, Wintum Environmental Protection Agency José Garcia Equity Research Rugh Henderson, MD, MPH North American Agromedicine Consortium, Pennsylvania Agromedicine Program, and Penn State University College of Medicine 117

126 Matthew Keifer, MD, MPH NIOSH Agricultural Health and Safety Centers, and University of Washington John McCarthy, PhD American Crop Protection Association Claudia Miller, MD University of Texas Health Science Center-San Antonio Madaleine Ochinang, MS Formerly with the Consortium for Environmental Education in Medicine Marcia Allen Owens, JD Minority Health Professions Foundation Annette Perez, RNC, MSN, CNM, PhD American College of Nurse Midwives, and University of Texas-El Paso, College of Health Sciences J. Routt Reigart, MD Medical University of South Carolina, Department of Pediatrics Elaine R. Rubin, PhD Association of Academic Health Centers Barbara Sattler, RN, DrPH University of Maryland, School of Nursing Leonel Vela, MD Migrant Health Advisory Council, and Texas Tech Health Sciences Center Federal Agency Representatives Elizabeth Blackburn, RN Office of Children s Health Protection, U.S. EPA Jerome Blondell, MPH, PhD Office of Pesticide Programs, U.S. EPA 118

127 Barbara Brookmyer, MD, MPH Bureau of Health Professions, Division of Medicine Health Resources and Services Administration Ruth Kahn, DNSc Bureau of Health Professions, Division of Medicine Health Resources and Services Administration Dalton Paxman, PhD Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services Rosemary Sokas, MD, MOH National Institute of Occupational Safety and Health Delta Valente, MPA Office Pesticide Programs, U.S. EPA Joan Weiss, PhD, RN, CRNP Bureau of Health Professions, Division of Nursing Health Resources and Services Administration Peter Wood, MS Agricultural Marketing Service, U.S. Department of Agriculture 119

128 Practice Workgroup Like the Education Workgroup, the Practice Workgroup spent a great deal of time discussing how to motivate change. Recognizing that primary care providers are busy and 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 care providers do not see enough acute cases of pesticide-related illness, they will not consider it important enough to pay attention. However, this is a classic Catch-22 situation, because if providers aren t aware of pesticide poisoning, they won t recognize the cases. The lack of data in this area makes it hard to convince primary care providers that they need to alter their practices. One way for primary care providers to be sensitized to the possibility of pesticide poisoning 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 be toxicologists. Instead, it is often patients who are directing physicians to focus more on pesticides and environmental health by the questions they bring up. Some workgroup members felt that it would be enough to have primary care providers be aware of the possibility of pesticide-related health conditions, know what questions to ask, and know where to go to get additional help. Others argued that minimum competencies, or practice changes, are needed. For example, a primary care provider shouldn t let a patient walk out of the office without ascertaining the possibility of exposure. The provider shouldn t just ask when a patient last vomited, but ask if the vomiting coincided temporally with something that happened at work. Knowing when to do a cholinesterase testing is extremely important for all primary care providers. Such testing, for example, is essential to establish that a person has been harmed for purposes of workers compensation, so that medical bills are reimbursed. 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. Two workgroup members pointed out that getting health care providers to ask a few simple questions would go a long way toward raising awareness of patients environmental health issues, without requiring these providers to do additional legwork in the community. Two 120

129 simple questions might be: (1) Where do you work? and (2) Do you think your problems are related to something that happened at work? The workgroup devoted an extensive amount of time to the discussion of competencies for primary care providers. (See Practice Component B on page 66 for more details.) Many workgroup members thought that although competencies was an appropriate term for an educational setting, in a practice setting the term implied that primary care providers are incompetent 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 primary care providers in certain communities should know more than providers in other areas. For example, should there be different levels of knowledge and skills for primary care providers in agricultural areas compared to providers in urban or suburban settings? While the issue was not resolved, the consensus appeared to be that all primary care providers should have a certain minimum content level of knowledge and skill related to pesticides/environmental health. On the other hand, it may be that primary care providers in agricultural communities have an added function, going beyond the minimum in recognition, diagnosis, and management pesticide-related illness to a larger role in prevention and education, and advising their patients about such things as heat stress, prenatal care, pesticides, etc. Making Change Happen How does change actually happen? Workgroup members discussed the difficulties in bringing about changes in health care. The literature on continuing education shows the need for a multifaceted approach. Continuing education alone has little impact without additional visits to clinics, feedback loops, hands-on workshops, etc. Even on grand rounds, occupational and environmental medicine subjects get very poor turnout. Other Issues Workgroup members stressed the need for research in a number of areas, including research on human exposure, biomonitoring, and the extent to which pesticide poisonings are currently being 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 these interconnections. For example, it is not clear that primary care providers realize the importance 121

130 of their role in reporting cases of pesticide illness both for regulating harmful pesticides and for efforts to make safer pesticides. Upon investigation, some incidents may turn out to have been a violation of the label restrictions; but in some cases, pesticide poisoning occurs with no apparent label violation. That information is extremely important, even if it cannot be proven 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 objective findings. Most pesticide illnesses yield signs and symptoms rather than objective findings, so patient claims may be denied. Primary care providers need help understanding what the medical rules of evidence are so that patient claims won t be rejected. One model might be Colorado s system 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 up their 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, only Washington State reimburses for diagnostic evaluations. Defining worker compensation requirements related to pesticide illnesses would attract the attention of medical associations and their members; physicians would know that they could get 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 reporting if it were used more widely. Despite the anticipated difficulties of affecting worker compensation systems, workgroup members agreed on the importance of tackling them. Half a dozen states are the sole insurers on worker compensation and in those states, the state commission would be the only organization to deal with. It was also pointed out that six states California, Texas, Florida, Oregon, Washington, and North Carolina probably cover 70 percent of agricultural workers, and might be the natural focus of attention for this type of effort. Workgroup members agreed that community health workers are an important part of the health care team. Caseworkers and community health workers are needed to go out and work with vulnerable populations. They can be particularly important in conducting follow up with migrant workers and bringing them back into the health care system. The workgroup raised, but did not reach a consensus on, whether to widen the scope of the initiative to involve the family, the role of the physician in the workplace, or the role of health professionals in the community. 122

131 Practice Workgroup Membership Co-Chairs Bonnie Rogers, RN, DrPH, COHN-S, FAAN American Association of Occupational Health Nurses and University of North Carolina-Chapel Hill, School of Public Health Karen Pane, RN, MPA, CMCN Health Resources and Services Administration U.S. Department of Health and Human Services Facilitator Susan West, MPH The National Environmental Education and Training Foundation, Inc. Members Sheila Brown Arbury, RN, MPH Association of Occupational and Environmental Clinics Shelley Davis Farmworker Justice Fund, Inc. J. Ward Donovan, MD, FACEP American College of Emergency Physicians, Pennsylvania University Poison Center, and Milton S. Hershey Medical Center Harold Harlan, PhD National Pest Control Association Barbara Hatcher, PhD, MPH, RN American Public Health Association Ann Linden, CNM, MSN, MPH American College of Nurse Midwives Mark Miller, MD American Academy of Pediatrics 123

132 Mary Miller, MN, ARNP American Nurses Association, and Washington State Department of Labor and Industries Karen Mountain, MBA, MSN, RN Migrant Clinicians Network Diane Mull Association of Farmworker Opportunity Programs Patrick O Connor-Marer, PhD American Association of Pesticide Safety Educators, University of California Statewide IPM Project, and University of California Agricultural Health and Safety Center John Pickle, RS, MSEH Weld County Health Department - Greeley, CO George C. Rodgers, Jr., MD, PhD American Association of Poison Control Centers, and University of Louisville School of Medicine Rachel Rosales, MSHP Texas Department of Health Cathy Simpson, MD Wayne State University, School of Medicine Gina Solomon, MD, MPH Natural Resources Defense Council Sheldon Wagner, MD National Pesticide Medical Monitoring Program, and Oregon State University John Wheat, MD, MPH North American Agromedicine Consortium, and University of Alabama at Birmingham, School of Medicine 124

133 Federal Agency Representatives Barbara Brookmyer, MD, MPH Bureau of Health Professions, Division of Medicine Health Resources and Services Administration Frank Davido Office of Pesticide Programs, U.S. EPA Eva Montoya, MSN, RN Bureau of Primary Health Care, Migrant Health Program, Health Resources and Services Administration Ana Maria Osorio, MD, MPH Office of Pesticide Programs, U.S. EPA Ana Marie Puente Bureau of Primary Health Care, Border Health, Health Resources and Services Administration Capt. Barry Stern, MPH Bureau of Health Professions, Health Resources and Services Administration 125

134 Resources Workgroup Building on the ideas of the Education and Practice Workgroups, the Resources Workgroup began its discussion by examining the types of resources that are used in educational and practice settings. The workgroup then undertook a more detailed exploration of key issues relating to resources, including: the credibility of sources of information, defining and understanding the audience, reaching the target audience with appropriate resources, and evaluating the effectiveness of resources. Credible Sources of Information The Resources Workgroup felt strongly that resources created or promoted through this initiative must be credible and scientifically sound. Credibility 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 Poisoning Prevention Program must form the basis for the initiative s efforts. The group explored the sources of information that health care providers and the public currently use, and the credibility of different information sources in different communities. One workgroup member suggested that the public trusts the universities first, the federal government next, state water agencies after that, and state agriculture departments after that. In many places, the community health worker plays a key role. There are 78 different names for community health workers in the U.S., and that although they are generally considered non-professional, they are the most trusted health care workers and have the highest ability to change behavior. Standards for community health workers are only starting to be developed as community colleges get involved in their training. Unfortunately, environmental health is not generally taught as part of their training. A related issue that the group considered is sensitivity to local concerns and parlance. Reaching the Target Audience The workgroup s discussions emphasized the importance of defining and understanding the target audience of primary care providers. Aware that the universe of health care providers runs into the millions, the group explored ways of segmenting the universe by type of provider, population served, and practice setting, or by matching types of providers to epidemiologic cases of pesticide use or abuse. 126

135 The workgroup devoted considerable time to a discussion of the varying levels of needs of primary health care providers. One workgroup member stated that it is not clear that we really know what health care providers want and need in the way of educational and information resources. It will be important to examine the extensive literature on how health professionals learn in order to determine the most effective approaches. The workgroup explored in detail the Stages of Change model created by Prochaska and DiClemente (Prochaska, 1995). The model looks as behavior change as a process rather than an event, and describes how individuals are at varying levels of motivation, or readiness to change. The model outlines a continuum of behavior change that can be used to help understand 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 Table 3 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, developed by The National Environmental Education and Training Foundation and mentioned additional materials. Workgroup members discussed all aspects of providing effective resources types of resource materials, settings in which they are delivered, delivery mechanisms, modes of dissemination, and motivation for use. Professional associations could play a big role in reaching member providers. The group discussed the types of technology that providers are most comfortable with, and acknowledged that while health care providers lag behind in their use of the Internet, they will no doubt increase their usage over time. Nevertheless, the Web can be a giant disorganized mess of bad data, good data, and it takes time to learn how to use it. Providers will continue to need quick and easy ways of accessing the information they seek. Some members argued that continuing medical education has been shown not to be an effective way to change behavior and that consensus statements of professional associations can take a long time to develop and to have an impact. It is important, however, to approach the target audiences and find out where they obtain information. Evaluating Results Some type of measurement and evaluation effort is certainly needed for this initiative. Evaluation and measurement are relevant for several purposes for assessing the baseline, i.e., the current state of awareness and involvement of primary care providers, for evaluating the quality of existing 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 degree to which educating health care providers on nutrition, tobacco, and other issues has led to 127

136 measurable changes in practice as well as changes in patient practices. Even with tobacco, the whole world is trying to get physicians to counsel their patients who smoke to stop smoking. Nevertheless, only percent of physicians appear to do so, and measuring this activity has been 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 the literature in this area. Several provider associations (clinics, pediatricians, family physicians, etc.) represented on this workgroup could provide a source for focus group participants. Other Issues The 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 by asking a question that the physician or nurse can t answer. Although primary care providers are often chiefly concerned with acute health effects, the public is increasingly leading the way in terms 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 is set. The group agreed that pesticides must continue to be seen in the context of environmental health as a whole. The importance of making primary care providers aware of preventive information along with diagnosis and treatment was continually stressed. Finally, the group discussed support for the initiative. There have been too many programs in government that just go away... If you don t have the money at the time you need it, it fades away. It is important that workgroup members go back to their organizations and discuss how the organizations can play a supporting role in implementing the initiative. The workgroup recommended that the federal representatives develop a broad outline of resource needs and federal commitments, as well as remaining needs for which extramural funding will be sought from industry, professional associations, and possibly environmental foundations and trusts. 128

137 Resources Workgroup Membership Co-Chairs Mark Robson, PhD, MPH Environmental and Occupational Health Sciences Institute, and Rutgers University Kevin Keaney, MA, MS Office of Pesticide Programs, U.S. Environmental Protection Agency Facilitator Susan West, MPH The National Environmental Education and Training Foundation, Inc. Members Colin Austin Migrant Clinicians Network, and University of North Carolina-Chapel Hill Angelina Borbon, RN Alameda County Lead Poisoning Prevention Program Barry Brennan, PhD American Association of Pesticide Safety Educators, and Extension Pesticide Coordinator, University of Hawaii Paul J. Brownson, MD The Dow Chemical Company Gerardo de Cosio, MD U.S.-Mexico Border Health Association Susannah Donahue, MPH Children s Environmental Health Network Gerry Eijkenmans, MD, MPH Pan American Health Organization 129

138 Scottie Ford, MA West Virginia Department of Agriculture Matthew Garabedian, MPH Texas Department of Health Allen James, MBA, CAE Elizabeth 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, MPH Association of Occupational and Environmental Clinics Terry Miller National Pesticides Telecommunications Network, and Oregon State University Rita Monroy National Alliance for Hispanic Health (formerly National Coalition of Hispanic Health and Human Services Organizations) Benjamin Ramirez, MD, MPH, FACOEM DuPont Company Scott Ratzan, MD, MPA Academy of Educational Development Susan Rehm, MBA American Academy of Family Physicians Barbara Sabol W.K. Kellogg Foundation Roger F. Suchyta, MD Graham Newson (alternate) Jennifer Stevens (alternate) American Academy of Pediatrics 130

139 Federal Agency Representatives Elizabeth Blackburn, RN Office of Children s Health Protection, U.S. EPA Jerome Blondell, MPH, PhD Office of Pesticide Programs, U.S. EPA Frank Davido Office of Pesticide Programs, U.S. EPA Jeanne Goshorn, MS National Library of Medicine Ron Hoffer, MS Office of Ground Water and Drinking Water, U.S. EPA Ameesha Mehta, MPH Office of Pesticide Programs, U.S. EPA Donna Orti, MS Agency for Toxic Substances and Disease Registry U.S. Department of Health and Human Services Karen Pane, RN, MPA, CMCN Health Resources and Services Administration U.S. Department of Health and Human Services Dalton Paxman, PhD Office of Disease Prevention and Health Promotion U.S. Department of Health and Human Services Sherri Umansky Office of Ground Water and Drinking Water, U.S. EPA Peter S. Wood Agricultural Marketing Service, U.S. Department of Agriculture 131

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