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Pillars of Governmental Environmental Public Health A Guide to Scalable Environmental Public Health Programs

Authors

Gina Bare, RN, National Environmental Health Association Thuy N. Kim, MPH, PhD, University of Minnesota School of Public Health Craig W. Hedberg, PhD, University of Minnesota School of Public Health Nicole Dutra, MPH, National Environmental Health Association Christopher Walker, MSEH, REHS, National Environmental Health Association David Dyjack, DrPH, CIH, National Environmental Health Association

Acknowledgements

The authors gratefully acknowledge the environmental public health professionals who participated in focus groups, key informant interviews, and the national field survey. Their generous contribution of time, expertise, and insights made this guide possible. We also thank the members of the Delphi panel who helped identify the core EPH programs, and the National Environmental Health Association Board of Directors for their support of this project.

Funding acknowledgement: Phase I of this two-phase project was supported by the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human Services (HHS) under federal award #NU38OT000300-04-07 in the amount of $25,000 or approximately 11% of the entire project. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. government.

Contents Introduction ………………………………………………………………………………………………………………………………………………………… 4

Background ………………………………………………………………………………………………………………………………………………………… 6

Characteristics of a Successful Environmental Public Health Department ……………………………………………………. 7

Core Environmental Public Health Programs …………………………………………………………………………………………………… 9 Food Safety and Protection …………………………………………………………………………………………………………………………………………………………..14

Swimming Pools and Recreational Water Safety ………………………………………………………………………………………………………………………17

Onsite Wastewater ………………………………………………………………………………………………………………………………………………………………………..19

School Safety and Inspection ……………………………………………………………………………………………………………………………………………………….23

Early Childcare and Daycare …………………………………………………………………………………………………………………………………………………………26

Zoonoses and Vector Control ……………………………………………………………………………………………………………………………………………………….28

Emergency Preparedness ……………………………………………………………………………………………………………………………………………………………..31

Potable Water ………………………………………………………………………………………………………………………………………………………………………………..34

Lead Prevention ……………………………………………………………………………………………………………………………………………………………………………..37

Body Art ………………………………………………………………………………………………………………………………………………………………………………………….40

Non-School Institutions and Licensed Establishments ……………………………………………………………………………………………………………..43

Secondary Environmental Public Health Programs ………………………………………………………………………………………..43 Climate Health ……………………………………………………………………………………………………………………………………………………………………………….44

Air Quality ……………………………………………………………………………………………………………………………………………………………………………………….45

Healthy Homes ………………………………………………………………………………………………………………………………………………………………………………45

Hazardous Materials ………………………………………………………………………………………………………………………………………………………………………46

Other Considerations for Secondary EPH Programs …………………………………………………………………………………………………………………47

Strategic Considerations for Program Enhancement………………………………………………………………………………………48 Building on Common Foundations ……………………………………………………………………………………………………………………………………………..48

From Guidelines to Implementation …………………………………………………………………………………………………………………………………………….49

The Evolving Landscape of Environmental Public Health ………………………………………………………………………………………………………..49

A Call to Action ………………………………………………………………………………………………………………………………………………………………………………49

Conclusion …………………………………………………………………………………………………………………………………………………………49

References …………………………………………………………………………………………………………………………………………………………50

Appendices ………………………………………………………………………………………………………………………………………………………..55

3

Environmental public health (EPH) professionals play a crucial role in safeguarding public health and ensuring the well-being and prosperity of our communities. Local governmental EPH programs employ a sig- nificant number of dedicated professionals who work tirelessly to pro- tect the food we consume, the air we breathe, the water we drink, and the environments in which we live, work, and play. The importance of local governmental EPH programs cannot be overstated, as they con- tribute to the overall health of the public and serve a vital function in national security.

Research has consistently demonstrated the positive impact of local health department (LHD) activities and investments on reducing the inci- dence of EPH-related diseases (Bekemeier et al., 2015; Fan et al., 2020). Moreover, senior leadership at both state and local health departments has recognized the essential nature of EPH services (Leider et al., 2015). Despite the crucial role EPH professionals play in promoting and protect- ing public health, national guidance on the optimal structure and organi- zation of local EPH departments is absent.

The absence of a standardized framework for local EPH departments poses significant challenges for EPH officials seeking to secure the nec- essary resources, including staff, funding, and equipment, to effectively carry out their duties. Without clear benchmarks and guidelines, EPH programs struggle to justify their needs, potentially compromising the health, safety, and prosperity of the communities they serve. To address this gap, this guide presents scalable program guidelines that can be adapted to meet the diverse needs, resources, and organizational struc- tures of EPH departments across different jurisdictions, while maintain- ing essential standards for protecting community health.

Introduction

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How This Document Was Developed

The Pillars of Governmental Environmental Public Health was developed through a comprehensive research collab- oration between the National Environmental Health Asso- ciation (NEHA) and the University of Minnesota (UMN) School of Public Health. This framework emerged from an extensive study conducted in 2024 that surveyed hun- dreds of environmental public health professionals across 45 states, the District of Columbia, and Puerto Rico. The research was built on previous work in 2023 that identified 11 core EPH programs through a Delphi panel of senior EPH professionals, followed by focus groups and key informant interviews to capture qualitative insights. This research was specifically designed to gather perspectives from EPH professionals, capturing insights on program structure, staffing standards, educational requirements, credentialing needs, and workload expectations across multiple program areas. The resulting guidelines pre- sented reflect the collective wisdom and practical expe- rience of hundreds of EPH professionals who understand the day-to-day realities of protecting public health while working within diverse organizational structures and resource constraints.

Scalable Guidelines Approach

The recommendations provided are intended as scalable guidelines rather than rigid requirements. Most jurisdic- tions possess unique EPH challenges, resources, demo- graphics, and governmental structures. What works in a large urban government agency might not be suitable for a

small, rural jurisdiction with different priorities and poten- tially fewer resources.

The scalable guidelines presented here offer a flexible framework that can be adapted to:

• Jurisdictions of varying sizes.

• Agencies with different levels of resources and staffing.

• Communities with distinct environmental health priorities based on culture, geography, climate, industry, and population characteristics.

• Diverse governance structures, including county, city, district, or combined jurisdictions.

• Inconsistent regulatory authorities granted under state and local laws.

The purpose of this guide is to provide EPH directors, man- agers, supervisors, and field staff with evidence-based recommendations that help them develop, implement, and sustain effective programs. These guidelines serve as a starting point for program assessment and advo- cacy efforts, offering benchmarks for staffing, education, training, certification, outcome measures, and equipment needs that can be adapted to match specific departmental and community circumstances. EPH leaders can consider these guidelines as a starting point for program develop- ment and assessment, adapting the recommendations to match their specific circumstances. Rather than present- ing a one-size-fits-all approach, this guide provides evi- dence-based parameters that can be scaled up or down based on department and community needs, regulatory responsibilities, and available resources.

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Pillars of Governmental Environmental Public Health | A Guide to Scalable Environmental Public Health Programs

EPH is a crucial facet of public health that focuses on the interplay between the intersection of environment and human health. It encompasses a wide array of programs and services designed to protect and enhance the health and well-being of communities. These programs iden- tify, assess, and mitigate environmental factors that can adversely impact human health.

The environment plays a significant role in shaping our health outcomes. Exposure to environmental hazards can lead to a range of health effects from acute illnesses to chronic diseases and premature death. According to the World Health Organization, an estimated 24% of the global disease burden and 23% of all deaths can be attributed to environmental factors (Prüss-Üstün et al., 2016). By addressing these environmental determinants of health, EPH professionals contribute to the preven- tion of disease, the promotion of health, and the overall well-being of communities.

EPH professionals comprise a diverse and highly skilled workforce, including specialists, scientists, technicians, and sanitarians. They possess expertise in a wide range of disciplines, such as epidemiology, toxicology, risk assess- ment, and environmental science. The EPH workforce is the second-largest profession within the public health workforce, after nursing (NACCHO, 2019). Despite their crucial role, EPH professionals often face numerous chal- lenges such as insufficient staffing, limited resources, and a lack of standardized guidelines for the structure and funding of EPH departments.

Local EPH departments play a vital role in protecting and promoting public health at the community level. They are

responsible for providing a wide range of services, includ- ing food safety inspections, water quality monitoring, haz- ardous waste management, vector control, and emergency preparedness, response, and recovery. These services are essential for preventing the spread of infectious diseases, reducing exposure to environmental hazards, and ensuring the overall health and safety of communities.

Studies have consistently demonstrated the positive impact of local EPH department activities and investments on pub- lic health outcomes. For example, Bekemeier et al. (2015) found that increased local health department food safety and sanitation expenditures were associated with signifi- cant reductions in enteric disease rates. Similarly, Fan et al. (2020) highlighted the critical role of EPH professionals in responding to the COVID-19 pandemic, emphasizing the importance of effective public health and safety nets in mit- igating the impact of public health emergencies.

Despite the clear evidence of the value of EPH services, local EPH departments often struggle to secure the nec- essary resources and support to carry out their essential functions effectively. The lack of national standards and guidance for the structure, staffing, and funding of EPH departments creates significant challenges for local public health officials in advocating for the resources necessary to protect the health of their communities.

This guide recognizes the importance of EPH and the need for a stronger, more resilient EPH system. Further, it provides national benchmarks and recommendations for the structure, staffing, and funding of local EPH depart- ments—a roadmap for strengthening the EPH workforce to ensure communities have access to essential services.

Background

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Pillars of Governmental Environmental Public Health | A Guide to Scalable Environmental Public Health Programs

A successful environmental public health department works to protect public health through prevention activities, respon- sive services, and community engagement while maintaining adaptability to emerging challenges. Based on findings from focus groups, interviews, and surveys with EPH profession- als, the following characteristics are commonly observed in well-performing environmental public health departments across various sizes, structures, and program configurations.

Silent Success Through Prevention

The hallmark of a well-functioning EPH department is often what does not happen—disease outbreaks pre- vented, environmental hazards mitigated, and injuries avoided. This “silent success,” sometimes referred to as “negative space,” represents the primary mission of EPH— prevention. When an EPH department functions optimally, the community might be largely unaware of its daily activ- ities, as the absence of environmental health crises often reflects effective performance.

Science-Based Decision-Making

EPH departments that perform well generally ground their operations in scientific evidence, using data collection, sur- veillance, and analysis to identify trends, determine prior- ities, and guide resource allocation. These departments typically maintain suitable data systems to track environ- mental conditions, monitor health outcomes, and evaluate program effectiveness, with decisions based on quantifi- able and relevant metrics.

Equitable Service Delivery

Excellence in EPH often involves identifying and address- ing disparities in environmental health conditions across populations and communities. High-performing depart- ments frequently assess the distribution of environmen- tal health burdens, target resources to areas of greatest need, and work to ensure services are accessible, cultur- ally appropriate, and designed to reduce health inequities.

Balance of Regulatory and Consultative Approaches

While enforcement of environmental health regulations remains essential, many departments increasingly balance traditional regulatory roles with consultative approaches.

This expanded model emphasizes education, technical assistance, and partnership with regulated entities to achieve compliance through collaboration rather than rely- ing primarily on fines and citations.

Effective Partner Relationships

The development and maintenance of strong relation- ships represents a core competency of many successful environmental public health departments. These relation- ships span regulated establishments, community partners, healthcare providers, academic institutions, and other governmental agencies. Strong relationships foster trust, enhance communication, facilitate information exchange, and extend the department’s impact beyond what can be achieved through direct service provision alone.

Workforce Excellence and Development

Effective EPH departments often invest in their workforce through comprehensive training, continuing education, and professional development opportunities. They cultivate environmental health professionals who possess technical expertise and skills in communication, customer service, cultural competence, and adaptability. These departments frequently create pathways for career advancement and knowledge transfer to ensure continuity of expertise.

Integration and Coordination

Effective EPH departments often integrate their services and coordinate across program areas. This integrated approach recognizes the interconnected nature of environ- mental health challenges and enables more efficient use of resources, reduces duplication of efforts, and provides more seamless services.

A successful environmental public health department works to protect public health through prevention activities, responsive services, and community engagement while maintaining adapt- ability to emerging challenges.

Characteristics of a Successful Environmental Public Health Department

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Pillars of Governmental Environmental Public Health | A Guide to Scalable Environmental Public Health Programs

Adequate and Sustainable Resources

Successful EPH departments work to secure and maintain the resources—funding, staffing, equipment, and facili- ties—necessary to fulfill their core functions. They often diversify funding sources, develop fee structures that reflect service costs, and effectively communicate their value to secure appropriate budget allocations. These departments typically maintain the capacity to respond to routine demands while remaining prepared for emergen- cies and emerging threats.

Continuous Quality Improvement

Excellence in EPH frequently involves ongoing assessment and improvement. Effective departments often establish meaningful performance measures, regularly evaluate their effectiveness, identify opportunities for enhancement, and implement changes based on evaluation findings. This culture of continuous improvement enables departments to adapt to evolving science, community needs, and envi- ronmental challenges.

Public Trust and Transparency

By maintaining transparent operations, clear communica- tion about environmental health risks and regulations, and demonstrated commitment to protecting public health, effective EPH departments often earn the trust of their

communities. This trust facilitates cooperation during rou- tine operations and proves valuable during emergency response situations when public compliance with health guidance becomes important.

The characteristics outlined above provide a framework for EPH departments to assess their current operations and identify opportunities for growth. While specific program implementations will vary based on community needs, regulatory requirements, and available resources, these foundational elements are commonly observed across well-functioning jurisdictions of various sizes.

Additional Resources

This guide also includes information on the 10 Essential Environmental Public Health Performance Standards and the Public Health Accreditation Board (PHAB) as appen- dices at the end of the document to provide additional context and guidance for program development and assessment. Additionally, EPH departments may find value in utilizing community health assessment (CHA) and community health improvement plan (CHIP) pro- cesses to identify local environmental health priorities and align program development with broader community health needs. Furthermore, a comprehensive reference section includes resources that were consulted during the development of this guide.

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Pillars of Governmental Environmental Public Health | A Guide to Scalable Environmental Public Health Programs

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Secondary EPH Programs

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Pillars of Environmental Public Health

A Guide to Scalable Environmental Public Health Programs

Core Environmental Public Health Programs Core EPH programs represent the most common and essential services that local EPH departments typically provide to protect and promote the health and well-be- ing of the communities they serve. These programs are designed to address the most pressing EPH concerns and are considered foundational to the mission of EPH. The 11 core EPH programs identified in research con- ducted by NEHA, in cooperation with UMN, include food safety and protection, potable water, swimming pools and recreational water safety, onsite wastewater, lead prevention, zoonoses and vector control, emergency pre- paredness, school safety and inspection, early childcare and daycare, body art, and non-school institutions and licensed establishments.

When local EPH departments focus on these core pro- grams, they can work to provide comprehensive services essential to safeguard public health. Delivery does require adequate staff, funds, and resources, which vary signifi- cantly across jurisdictions.

In addition to the 11 core EPH programs, local EPH departments can also provide secondary programs that address specific EPH concerns within their jurisdictions. These secondary programs (e.g., climate health, air qual- ity, healthy homes, hazardous materials) could be con- sidered core programs by some departments based on the unique needs and priorities of the communities they serve (NEHA, 2022).

The determination of which programs might be consid- ered core or secondary likely varies across jurisdictions, as EPH challenges and community needs can differ significantly from one area to another. For example, a jurisdiction with a history of poor air quality or indus- trial pollution might prioritize air quality monitoring and enforcement as a core program, while another jurisdiction could focus on healthy homes due to elevated rates of childhood asthma.

To effectively identify and prioritize core and secondary EPH programs, local EPH departments can collect and analyze data on the EPH status of their communities, assess community needs and priorities, review appli- cable regulatory requirements, and engage with inter-

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Pillars of Governmental Environmental Public Health | A Guide to Scalable Environmental Public Health Programs

ested partners. This data-driven, community-informed approach can help ensure that EPH departments allocate their resources and efforts toward the programs that will have the greatest impact on protecting and promoting public health.

When local EPH departments tailor their core and second- ary EPH programs to the specific needs of their communi- ties, they can develop a comprehensive, responsive, and effective EPH strategy that addresses the most pressing concerns and promotes health equity.

In the sections that follow, we define each core EPH pro- gram based on comprehensive research conducted jointly by NEHA and UMN. Through focus groups, interviews, and a national field survey with participants from hundreds of diverse local EPH departments, we provide meaningful outcome measures, staffing benchmarks, educational and certification requirements, essential equipment needs, and common funding sources for each program. This evi- dence-based information enables EPH departments to develop strong, sustainable programs tailored to their communities’ unique needs.

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Pillars of Governmental Environmental Public Health | A Guide to Scalable Environmental Public Health Programs

Core Environmental Public Health Programs at a Glance: Key Findings and Recommendations The following table provides an overview of 10 of the 11 core EPH programs identified through our research. This summary synthesizes key findings from focus groups, inter- views, and surveys with EPH professionals nationwide to present essential information for each program area. The 11th program area, Non-School Institutions and Licensed Establishments, is not included in this table due to the sig- nificant variability in how jurisdictions define and organize the

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