# Creating a Children\'s Environmental Health Program

#  2006 - 2007 

# 

#  Environmental Public Health Leadership Institute Fellows:

**Peter J. Isaksen, R.S**.

*Health & Environmental Investigator II*

Special Projects

Public Health -- Seattle & King County

*999 Third Avenue, Seattle, WA, 98104-4039*

*206-296-4724, <peter.isaksen@metrokc.gov>*

**Jefferson S. Ketchel, R.S.**

*Health & Environmental Investigator III*

Local Hazardous Waste Management Program

Public Health -- Seattle & King County

*999 Third Avenue, Seattle, WA, 98104-4039*

*206-296-4731, <jefferson.ketchel@metrokc.gov>*

**Tracee Mayfield, R.S.**

*Health & Environmental Investigator II*

Local Hazardous Waste Management Program

Public Health -- Seattle & King County

*999 Third Avenue, Seattle, WA, 98104-4039*

*206-296-3928, <tracee.mayfield@metrokc.gov>*

# Mentor:

### **Charles D. Treser, MPH**

*Senior Lecturer*, Department of Environmental Health

School of Public Health and Community Medicine

University of Washington

# Acknowledgements:

**Ngozi T. Oleru, Ph.D.**

*Division Director*

Environmental Health Services Division

Public Health -- Seattle & King County

**Ken Armstrong**

*Program Administrator*

Local Hazardous Waste Management Program in King County

**Sherry Immediato, MBA**

*Managing Director*

Society for Organizational Learning

Cambridge, MA

**Robin Kenepah, BSN**

*Public Health Nurse*

Public Health -- Seattle & King County

**Local Hazardous Waste Management Program in King County**

**Public Health -- Seattle & King County**

**National Center for Healthy Housing**

**Washington State Department of Health Office of Environmental Health
Assessment**

![](media/image1.jpeg){width="1.3756944444444446in"
height="0.6368055555555555in"}

# EXECUTIVE SUMMARY:

'Our vision is toxics free and healthy children becoming healthy
adults.'

This project proposes to create a Children's Environmental Health (CEH)
Program in King County, WA that focuses our collective thinking on life
stages and disease causes rather than environmental conditions or
particular hazards. Historically, we have collected grant money and
attacked each health issue as an isolated entity. The proposed plan
would create a broadly supported program from which individuals can view
the big picture, develop messages and directly respond by closing gaps
and coordinating overlaps for CEH. The result will be a stable program
which will be the intersection of assessment, policy creation and
assurance delivery for CEH planning and action.

The different environments that affect a child's health include their
home, school, childcare and playground. The impacts from these
environments attract stakeholders with various interests, skills and
capacities. The project team utilized the ten essential services of
environmental-public health and the national goals of *Healthy People in
Every Stage of Life* and *Healthy People in Healthy Places* in designing
this project.

By implementing the ten essential services wheel and applying it to each
*Place* of a child's environment, one can develop a plan of assessment,
policy development and assurance. The project team, with tremendous
input, leadership and assistance from their division and program
partners, started with childcares.

Methods included discussions with key external stakeholders regarding
perceptions and realities of CEH needs and services. They were asked a
series of questions regarding the role that Environmental-Public Health
and the proposed CEH program should undertake, as well as about programs
to model and potential funding sources.

# INTRODUCTION/BACKGROUND:

Children are more vulnerable to environmental exposures than adults
because their bodily systems are still developing. They eat more, drink
more, and breathe more in proportion to their body size and their
behavior can expose them more to chemicals and organisms. In King County
Washington, many governmental, quasi-governmental, and non-governmental
agencies are working to protect the environmental health of children.
However, there is no comprehensive entity that looks at the whole
system, assesses the effectiveness, and tries to find and solve the gaps
and overlaps in services to ensure the maximum protection is in place
for children. The questions of "are we being effective," and "what else
can or should we be doing" are not being answered in a systemic way for
children in King County. Our team was put together to propose a plan for
creating a Children's Environmental Health Program in our county. With
this Program we will provide a consistent, relevant, and empowering
Environmental Health presence where children live, learn and play.

***Problem Statement:***

**Goal:**

-   Develop a Children's Environmental Health (CEH) program with a
    stable funding base so that Public Health-Seattle & King County
    (PHSKC) can provide community leadership, coordination and services
    to meet the environmental health needs of children in King County.
    This program will include assessment, assurance and direct service
    activities.

**Issues and Contributing Factors:**

-   King County lacks a coordinated delivery of environmental health
    services to children. CEH services are currently provided by
    isolated projects and programs separated by funding streams.

-   There is no cross-divisional/departmental effort to identify the CEH
    needs and implement policies for children.

-   Programs that, in the past, provided significant child environmental
    health impact, such as Indoor Air Quality and Healthy Homes, have
    recently been severely reduced or eliminated due to ongoing budget
    challenges as a result of a policy shift to fee for services.

-   CEH programs and activities lack billable fees and thus a stable
    funding source.

-   There is a lack of community participation, knowledge and priorities
    regarding CEH issues.

-   Relationships with local school districts remain problematical due
    to regulatory unfunded mandates.

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-   No local funding is provided specifically to address children's
    environmental health needs.

-   Many parents are unaware of their child's environmental health
    needs. This is frequently evident as environmental health issues are
    not factored into childcare selection.

-   A comprehensive local needs assessment for the environmental health
    status of children in King County is missing.

**Why intervention is needed?**

-   Children are a sensitive and vulnerable population. Children are not
    little adults; their bodies are developing at a very fast rate. They
    eat more, drink more and breathe more in proportion to their body
    weight that adults. They are also closer to the ground and explore
    their surroundings by touching and tasting.

-   Specific issues that may be impacting children's health include:
    'Healthy Housing' conditions (especially lead and indoor air
    quality), outdoor air quality, persistent bio-accumulative toxins
    and endocrine disruptors, school environments, environmental tobacco
    smoke, hazardous waste sites, contaminated soils, and global
    warming.

-   There is no coordinated, effective CEH community education and
    involvement. Some Environmental Health messages seem contradictory
    coming from all of the various sources, so the public is confused
    and does not know what to believe or how to proceed to protect their
    children.

**Who is on the team?**

-   Public Health -- Seattle & King County

-   Local Hazardous Waste Management Program in King County

-   Washington State Department of Health

-   Washington State Department of Early Learning

-   Washington State Department of Community, Trade and Economic
    Development

-   Collaborative on Health and the Environment in Washington

-   Institute for Children's Environmental Health

-   National Center for Healthy Housing

-   Others stakeholders as identified during CEH program development.

**Indicators of Success:**

-   The CEH needs assessment for King County is completed.

-   The development of the CEH Logic Model is continued and improved.
    The project moves in a timely manner through Project Planning,
    Exploration, Support Generation, Funding Development, and Program
    Development. Finally, the proposal is accepted; CEH Program exists.

-   CEH services and/or activities are continued and expanded. Gaps and
    overlaps are identified and addressed.

-   Linkages are created with the community so that the community has
    ownership of CEH Program with problem solving involvement.

-   Long term, stable funding is procured from three areas: state
    legislature, King County Board of Health, and grants.

-   Parents are informed about environmental health issues.

-   A system to monitor, collect and assess local children's
    environmental health indicators is created, maintained and data used
    for assurance.

-   The Environmental Health of King County children is protected.

-   Toxics free and healthy children do grow up to be healthy adults in
    King County.

####### 

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####### 

####### ***Behavior Over Time Graph:***

####### 

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1.  The typical response to a rising Child Health Issue is illustrated
    by the Cases (in black) rising over time. As an example the cases
    can be requests for Asthma intervention services. As the Asthma rate
    increases there are more requests for EH staff Response.

2.  Normally the next step would be to find a Grant (Grant1) that can
    pay for the staff training as well as paying for some of the
    response, as this money is not available in the existing budget.
    There is a lag in the EH Response as staff is brought up to speed on
    what needs to be done. Also, as word of the grant gets out, the
    demand for service increases.

3.  Since the first grant does not pay enough to make a significant
    impact in closing the gap between the cases and the response another
    grant is applied for (Grant 2). Again, there is a slight lag as
    additional staff are brought up to speed, and again the demand for
    service increases in the short term.

4.  This approach appears to have addressed the issue in the short term.
    Unfortunately Grant 1 sunsets and although the money is no longer
    coming in, the staff still tries to respond at the full level. Of
    course this is short lived, and then staff are diverted to other
    tasks.

5.  Finally grant 2 sunsets, and although it looks like the response was
    working in the short term, in the long term the need for
    interventions has in fact increased. Since there is no more money
    available, either the services are discontinued, or more likely the
    staff is forced to respond to Asthma interventions while doing other
    work for programs that have money. The net effect being that EH is
    seen as unresponsive and untrustworthy by the Public; staff morale
    suffers and EH loses its effectiveness in the community.

***Casual Loop Diagrams and Applicable Archetypes***

####### ***10 Essential Environmental Health Services:***

The Ten Essential Services of Environmental-Public Health was the most
useful tool used in developing this project. The services clearly
spelled out what efforts were required to accomplish specific outcomes.
It also helps to define next steps as development of the Children's
Environmental Health Program in King County continues.

An essential services wheel was assigned to each *Place* a child spends
time, specifically childcares, schools, homes and playgrounds.
Childcares were selected as the first place to assess.

![](media/image2.png){width="3.1381944444444443in"
height="3.1527777777777777in"}

*Childcare Assessment*

In 2006, the Local Hazardous Waste Management Program in King County
completed the field component of a childcare risk assessment coordinated
by Tracee Mayfield. The field component consisted of environmental
health professionals visiting 206 of the existing 2000 childcare homes
and centers in King County. The assessment survey included observations
and questions on chemical asthmagens, cleaners and art supplies; or
lead, phthalates and pesticides. All childcares visited received the
same questions regarding what environmental health issues should be
examined in the child care industry and what technical support and
incentives should King County offer. Diagnosing and investigating
childcares included observations, measurements, and stakeholder
questions to the operators. The "Monitoring Health" component is the
next step and will take the form of a King County Children's Morbidity
Report.

*Childcare Policy Development*

During the childcare risk assessment project development, a planning
group was convened to help steer the project and provide feedback on
proposed tools. This planning group will reconvene when the risk
assessment report is complete so that recommendations can be created for
policy development. The stakeholders participating in the planning group
represent different aspects of the childcare community. When policies
are created, there will be an outreach to inform, educate and empower
childcares in King County.

*Childcare Assurance*

This section's primary focus will be to assure the linkage of childcare
operators, parents and children to the aforementioned policies' services
and education. These policies are yet to be developed.

####### ***National Goals Supported*** 

[This project lends well with the CDC's national health protection
goals.]{.underline}

*Healthy People in Every Stage of Life*

This project focused primarily on two of the life stages described in
this national goal; *Start Strong* (infants and toddlers, ages 0-3
years) and *Grow Safe and Strong* (children, ages 4-11 years). By
developing a children's environmental health program, we can help assure
physical environments that support the health, safety and development of
children, infants and toddlers; and prevent chronic diseases and their
consequences among children.

*Healthy People in Healthy Places*

This national goal focuses on the places where people live, work, learn,
and play. For this project, we focus on where children live, learn and
play; which includes homes, childcares, schools and playgrounds.

[This project lends well with the CDC's National Strategy to Revitalize
Environmental Public Health Services.]{.underline}

*Goal VI (Create Strategic Partnerships)*

The intent of this goal is to foster partnerships among various
agencies, organizations, and entities that influence environmental
public health services and practice to advance marketing, communication,
research, and training-program initiatives. This goal will also foster
communication and interaction among stakeholders, especially policy
makers.

This project has required our team and colleagues to engage stakeholders
including government, non-governmental organizations, and the public.
Developing these partnerships have been critical to the short and long
term successes of this project.

####### ***Project Logic Model:***

+--------+--------+--------------------+------------------------------+
| **P    | *      | **Activities**     | **Outputs**                  |
| roject | *Resou |                    |                              |
| Compon | rces** |                    |                              |
| ents** |        |                    |                              |
+========+========+====================+==============================+
| **A -  | 1)     | 1)  EPHLI          | 1)  EPHLI Participation      |
| P      |  EPHLI |     Participation  |                              |
| roject |        |     -- develop     | 2)  EPHLI Homework           |
| Plan   |   Ment |     program        |                              |
| ning** | orship |     analysis and   |     a.  Stake holder matrix  |
|        | -Chuck |     policy         |                              |
|        |        |     development    |     b.  Systems analysis     |
|        | Treser |     skills         |         models ( 2 to 4)     |
|        |        |                    |                              |
|        |        | 2)  Complete EPHLI |     c.  Project logic model  |
|        |        |     Project        |                              |
|        |        |     Assignments    |     d.  Project abstract     |
|        |        |                    |                              |
|        |        | 3)  Generate       |     e.  Project report       |
|        |        |     Project Work   |                              |
|        |        |     Plan           |     f.  Project Presentation |
|        |        |                    |                              |
|        |        | 4)  Explore Stake  |     g.  Oral Project         |
|        |        |     holder support |         Presentation         |
|        |        |                    |                              |
|        |        | 5)  Identify and   | 3)  CEH Program Proposal     |
|        |        |     describe       |     Work Plan                |
|        |        |     current        |                              |
|        |        |     Children's     | 4)  Stake holder matrix      |
|        |        |     Environmental  |                              |
|        |        |     Health ( CEH ) | 5)  Written summary on       |
|        |        |     Program Models |     current CEH Programs     |
|        |        |     (e.g. Region 8 |     Proposal Work Plan (10   |
|        |        |     EPA)           |     pages)                   |
+--------+--------+--------------------+------------------------------+
| **B -  | 1)     | 1)  Gather         | 1)  Problem Statement        |
| Explo  |  Jeff, |     available      |     (report 80 pages)        |
| ration |     T  |     information on |     containing               |
| (p     | racee, |     Current State  |                              |
| roblem |        |     of Children's  |     a.  Target audience      |
| defi   | Peter, |     Environmental  |         description          |
| nition |     .3 |     Health in King |                              |
| and    |        |     County         |     b.  Health problems      |
| c      |    FTE |                    |         present              |
| urrent |        | 2)  Evaluate       |                              |
| activ  |  total |     existing       |     c.  Known CEH exposures  |
| ity)** |        |     programs which |                              |
|        | 2)     |     can create a   |     d.  Existing services    |
|        |   Ment |     model of CEH   |         /resources (inc.     |
|        | oring, |     for King       |         NGO)                 |
|        |        |     County.        |                              |
|        |  consu |                    |     e.  Service short falls  |
|        | lting, |                    |         and issues           |
|        |        |                    |                              |
|        |    and |                    |     f.  Knowledge gaps       |
|        |        |                    |                              |
|        |   prod |                    |     g.  Funds currently used |
|        | uction |                    |         for CEH activities   |
|        |        |                    |                              |
|        |   assi |                    | 2)  Analysis of up to 5      |
|        | stance |                    |     existing CEH programs    |
|        |        |                    |     which can contribute to  |
|        | 3)     |                    |     a model for King County  |
|        |  Trudy |                    |     which contains (20       |
|        |        |                    |     pages) which looks at;   |
|        | 4)     |                    |                              |
|        |   Over |                    |     a.  Program goals        |
|        | sight, |                    |                              |
|        |        |                    |     b.  Activities           |
|        |  Ryan, |                    |                              |
|        |        |                    |     c.  Funding sources      |
|        |   Lee, |                    |                              |
|        |        |                    |     d.  Program development  |
|        |   Bill |                    |         history              |
|        |        |                    |                              |
|        | 5      |                    |                              |
|        | )  Gui |                    |                              |
|        | dance, |                    |                              |
|        |        |                    |                              |
|        |    men |                    |                              |
|        | toring |                    |                              |
|        |        |                    |                              |
|        |  Ngozi |                    |                              |
|        |        |                    |                              |
|        | Tu     |                    |                              |
|        | telage |                    |                              |
|        | CDC    |                    |                              |
+--------+--------+--------------------+------------------------------+
| **C-S  | 1)     | 1)  Identify       | 1)  Stakeholder Input        |
| upport |  Stake |     approach and   |                              |
| Genera | holder |     collect input  |     a.  Updated Stakeholder  |
| tion** |        |     from stake     |         matrix               |
|        |   rep. |     holders        |                              |
|        |        |                    |     b.  Forty interviews     |
|        |    and |     a.  Networking |         with stakeholders    |
|        |     p  |         activity   |                              |
|        | roject |                    |     c.  Two Stakeholder      |
|        |        |     b.  Interviews |         focus group meetings |
|        |    cha |                    |                              |
|        | mpion: |     c.  Meetings   | 2)  Six Public Focus group   |
|        |        |                    |     meetings to identify     |
|        |    Bud | 2)  Identify       |     perceived PH obligations |
|        |        |     community      |     in CEH and desired       |
|        | Nicola |     expectations   |     needed services or roles |
|        |        |     of PH role in  |     of PH.                   |
|        | 2)     |     CEH            |                              |
|        |   Carl |     activities.    | 3)  Ten anecdotal stories    |
|        |        |                    |                              |
|        | Osaki? | 3)  Collect        | 4)  Identify BOH and X (give |
|        |        |     anecdotal      |     bodies) information      |
|        | 3)     |     information /  |     needs for creation of a  |
|        |  Other |     stories--      |     CEH program              |
|        |        |     which identify |                              |
|        |  Stake |     EPH problems   | 5)  Identify plausible       |
|        | holder |     created, by    |     funding strategy         |
|        |        |     gaps in        |     supports                 |
|        | 4      |     publicly       |                              |
|        | )  EPE |     available      |                              |
|        |        |     services and   |                              |
|        |        |     stories which  |                              |
|        |        |     identify the   |                              |
|        |        |     creation of    |                              |
|        |        |     unintended     |                              |
|        |        |     barriers to    |                              |
|        |        |     CEH            |                              |
|        |        |     protection, in |                              |
|        |        |     respect to     |                              |
|        |        |     public health  |                              |
|        |        |     activities or  |                              |
|        |        |                    |                              |
|        |        |    non-activities. |                              |
|        |        |                    |                              |
|        |        | 4)  Use current    |                              |
|        |        |     opportunities  |                              |
|        |        |     to develop     |                              |
|        |        |     partnerships   |                              |
|        |        |     with potential |                              |
|        |        |     stakeholders   |                              |
+--------+--------+--------------------+------------------------------+
| **D -  |        | 1)  Develop        | 1)  Funding Evaluation       |
| F      |        |     Criteria for   |     Criteria                 |
| unding |        |     evaluation /   |                              |
| D      |        |     ranking of     | 2)  Analysis of five         |
| evelop |        |     funding        |     potential funding        |
| ment** |        |     strategies     |     strategies complete with |
|        |        |                    |     predictions for support  |
|        |        | 2)  Analysis of    |     and feasibility,         |
|        |        |     funding ideas  |     equitability and         |
|        |        |     generated in C |     sustainability           |
|        |        |     & D            |                              |
|        |        |                    | 3)  Ranked list of funding   |
|        |        | 3)  Comparison and |     suites                   |
|        |        |     ranking for    |                              |
|        |        |     proposal       |                              |
+--------+--------+--------------------+------------------------------+
| **E -  |        | 1)  Assemble       | 1)  Plan completed           |
| P      |        |     information    |                              |
| rogram |        |     into program   |                              |
| D      |        |     plan through   |                              |
| evelop |        |     Needs          |                              |
| ment** |        |     Assessment     |                              |
|        |        |     completion     |                              |
+--------+--------+--------------------+------------------------------+
| **F    |        | 1)  Plan is        | 1)  CEH Program exists       |
| --Prop |        |     proposed       |                              |
| osal** |        |                    |                              |
+--------+--------+--------------------+------------------------------+

Logic Model for the development of a Children's Environmental Health
Program (Page 1 of 2)

Goal: To have toxics free and healthy children becoming healthy adults.

####### ***Project Logic Model cont.:***

+-------+-----------------------------+-----------------+------------+
| **Pr  | **Outcomes**                | **Indicators**  | **Data     |
| oject |                             |                 | Collection |
| Co    |                             |                 | Method**   |
| mpone |                             |                 |            |
| nts** |                             |                 |            |
+=======+=============================+=================+============+
| **A - | 1)  EH has a strategy for   | 1)  CDC         |            |
| Pr    |     developing a CEH        |     Comments    |            |
| oject |     Program to propose to   |     Received    |            |
| Plann |     present to the Board of |                 |            |
| ing** |     Health.                 | 2)  Proposal    |            |
|       |                             |     strategy    |            |
|       | 2)  Enhancement of EHD      |     accepted    |            |
|       |     policy analysis and     |     and         |            |
|       |     program development     |     supported   |            |
|       |     skills.                 |     by EH       |            |
|       |                             |     Division    |            |
|       |                             |     management  |            |
+-------+-----------------------------+-----------------+------------+
| **B - | 1)  Children's              | 1)  Problem     |            |
| E     |     Environmental Health    |     Statement   |            |
| xplor |     problem in King County  |                 |            |
| ation |     is well described.      | 2)  Comments    |            |
| (pr   |                             |     received:   |            |
| oblem | 2)  Understanding of        |                 |            |
| defin |     existing CEH program    |                 |            |
| ition |     models.                 |    a.  Internal |            |
| and   |                             |                 |            |
| cu    | 3)  Understanding of        |      --Division |            |
| rrent |     current CEH morbidity   |                 |            |
| a     |     data sources.           |      Management |            |
| ctivi |                             |                 |            |
| ty)** | 4)  Clear CEH morbidity     |                 |            |
|       |     data needs.             |   b.  External: |            |
|       |                             |         BOH     |            |
|       |                             |                 |            |
|       |                             | representation, |            |
|       |                             |         DOH,    |            |
|       |                             |                 |            |
|       |                             |        Ecology, |            |
|       |                             |         EPA,    |            |
|       |                             |         CDC,    |            |
|       |                             |         other   |            |
|       |                             |         as      |            |
|       |                             |                 |            |
|       |                             |       indicated |            |
|       |                             |         by      |            |
|       |                             |         Ngozi   |            |
+-------+-----------------------------+-----------------+------------+
| *     | 1)  Increased knowledge and | 1)  Twenty      | 1)         |
| *C-Su |     support by stakeholders |     percent     |  Interview |
| pport |     for a CEH program.      |     increase in |            |
| Ge    |                             |     stake       |  questions |
| nerat | 2)  Stakeholders' visions   |     holder      |            |
| ion** |     and expectations for    |     support,    | 2)  Notes  |
|       |     PHSKC CEH activities    |     (As         |     form   |
|       |     will be understood.     |     measured by |     public |
|       |                             |     CDC support |            |
|       | 3)  Increased awareness of  |     matrix.)    |   meetings |
|       |     CEH issues by           |                 |            |
|       |     stakeholders.           | .               | 3          |
|       |                             |                 | )  Stories |
|       |                             |                 |            |
|       |                             |                 | 4          |
|       |                             |                 | )  Letters |
|       |                             |                 |     /      |
|       |                             |                 |     emails |
|       |                             |                 |     of     |
|       |                             |                 |            |
|       |                             |                 |    support |
+-------+-----------------------------+-----------------+------------+
| **D - | 1)  EHD has increased       | 1)  Included in |            |
| Fu    |     knowledge of potential  |     project     |            |
| nding |     funding sources.        |     proposal    |            |
| Dev   |                             |                 |            |
| elopm | 2)  Recommended suite of    |                 |            |
| ent** |     funding source for      |                 |            |
|       |     project proposal.       |                 |            |
+-------+-----------------------------+-----------------+------------+
| **E - | 1)  A time table for a      | 1)  Reviewers'  |            |
| Pr    |     program proposal exists |     comments.   |            |
| ogram |                             |                 |            |
| Dev   | 2)  An evaluated plan, with |                 |            |
| elopm |     stake holder            |                 |            |
| ent** |     contribution for        |                 |            |
|       |     creating a CEH program  |                 |            |
|       |     proposal completed.     |                 |            |
|       |                             |                 |            |
|       | 3)  CEH activities in KC    |                 |            |
|       |     will be coordinated and |                 |            |
|       |     synergistic.            |                 |            |
|       |                             |                 |            |
|       | 4)  Gaps and overlaps       |                 |            |
|       |     identified, strategy    |                 |            |
|       |     for addressing them     |                 |            |
|       |     completed.              |                 |            |
+-------+-----------------------------+-----------------+------------+
| **F   | 1)  Morbidity related to    |                 |            |
| -     |     childhood environmental |                 |            |
| Propo |     exposures in King       |                 |            |
| sal** |     County will be reduced. |                 |            |
|       |                             |                 |            |
|       | 2)  Increased awareness of  |                 |            |
|       |     CEH issues by           |                 |            |
|       |     stakeholders.           |                 |            |
|       |                             |                 |            |
|       | 3)  Increased Public Trust  |                 |            |
|       |     in Public Health.       |                 |            |
|       |                             |                 |            |
|       | 4)  CEH activities in King  |                 |            |
|       |     County will be          |                 |            |
|       |     coordinated,            |                 |            |
|       |     synergistic and cost    |                 |            |
|       |     effective.              |                 |            |
|       |                             |                 |            |
|       | 5)  Increased cooperation   |                 |            |
|       |     in the CEH related      |                 |            |
|       |     activities in King      |                 |            |
|       |     County between stake    |                 |            |
|       |     holders and EHD.        |                 |            |
+-------+-----------------------------+-----------------+------------+

Logic Model for the development of a Children's Environmental Health
Program (Page 2 of 2)

Goal: To have toxics free and healthy children becoming healthy adults.

# PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES:

####### ***Program Goal***

Toxics free and healthy children become healthy adults.

####### ***Health Problem***

Children are vulnerable and at high risk from environmental conditions
and exposures. No comprehensive/coordinated CEH program currently
exists.

####### ***Outcome Objective***

**Current**

By February 1, 2007 King County will have created a plan for designing a
CEH program.

**Future (Post EPHLI)**

By January 1, 2008 CEH program development will have legislative (BOH)
approval.

By January 1, 2009 King County will have developed a CEH Program

By January 1, 2010 King County will have implemented a CEH Program

####### ***Determinant***

The number of children and adults that develop health problems due to
childhood exposures

####### ***Impact Objective***

Amount of diseases related to childhood exposures will be reduced.

####### ***Contributing Factors***

There is a lack of; comprehensive knowledge regarding regional CEH risk
and exposure issues, point of contact with access to all available CEH
issues, and an underdevelopment of CEH related services.

####### ***Process Objectives***

**By Feb 1, 2007 a plan will be complete for proposing the KC CEH
program**.

# METHODOLOGY:

***Planning***

By working with EPHLI tools we created a description of the problem, a
logic model for addressing the problem, and a multiyear plan for the
creation of a CEH program.

Childcares were selected as the first of four areas this project will
assess; with the other three being homes, schools, and playgrounds. Also
during the assessment, stakeholders from public health nursing, the
regulatory community, and epidemiology were engaged to help develop the
assessment and plant seeds for later community mobilization.

***Communication and Partnerships***

We used every available means to communicate and discuss the goal of
creating a comprehensive CEH program with both internal and external
stakeholders. This was done through the utilization of an advisory
group, holding meetings with upper management, and with attendance at
meetings hosted by other entities (both regional NGO and governmental)
having congruent or synergistic activities or agendas.

***Childcare Care Assessments & Interviews***

Childcares hold a unique opportunity to measure and intervene on
children's environmental health issues. First, many children 0-5 spend a
great deal of their waking moments in childcares. There are
approximately 1250 childcare homes and 750 childcare centers in King
County. Conservatively, this means there are at approximately 20,000 of
the 107,000 children aged 0-5 in King County who spend time in
childcares.

We conducted chemical hazard assessments and interviews in just over two
hundred child care facilities, which is roughly 10 percent of the all
the licensed facilities in King County. The assessment and interview
design was created by working with an advisory panel. As of this
report's writing, all data (with the exception of the lead wipe data)
has been collected and stored in a database. The lead wipe data will be
correlated with visual assessments and added to the database at a later
time. Staff work plans show the data will be analyzed in the first
quarter of 2007. A preliminary review of the interview has been
completed and a multivariate analysis will be completed in the second
quarter of 2007.

***Stakeholder Interviews***

A stakeholder interview was developed to collect information on
perceived CEH risks, knowledge of current CEH related activities and
contacts, external expectations of public health, potential funding
mechanisms, suggestion for appropriate activities, and to explore
potential partnership areas. This interview was reviewed by PHSKC
communications staff and piloted with one representative each from
academia (University of Washington), government (Region 10,
Environmental Protection Agency), and non-government organizations (The
Institute for Children's Environmental Health.)

***Strategic Planning Linkages***

We worked on components of a reorganization for the strategic plan of
the Local Hazardous Waste Management Program in King County (LHWMP).
Applying leadership skills, problem analysis and communications,
partnering, and other relevant skills developed during EPHLI, we worked
to incorporate CEH work and program development activities into the 4
year strategic plan.

# RESULTS:

***Planning***

"We have a plan."

***Communication and Partnerships***

While working on this project we created and/or strengthened CEH
partnerships with:

-   Washington State Department of Health, Division of Environmental
    Health, Office of Risk Assessments

-   Washington State Department of Early Leaning,

-   American Lung Association of Washington

-   Collaborative on Health and the Environment

-   Region 10 EPA

-   Institute for Children's Environmental Health

-   National Center for Healthy Housing

***Childcare Care Assessments & Interviews***

During visits, child care operators were interviewed and asked to
express concerns and needs knowledge relating to CEH. The interview was
based on three question given in a conversational format (non verbatim
with adjustments in presentation and dialect). Interviewers were trained
to encourage the interviewees to follow their own conversation threads.
All questions were open ended and the last question was only an
encouragement of "anything else" The other two questions were; "We have
asked you several questions about specific environmental health issues.
Are there any other similar issues you think we should be aware of, or
looking at, in the child care industry?" and, "What technical support
and incentives do you think King County should offer to child care
providers?" An initial response analysis shows 419 distinct responses
collected. Below is list of identified recurring themes and the portion
of providers who mentioned

  --------------------------------------------------------------- ---------
  Theme                                                           Percent

  Passive education increase; e.g. newsletters, brochures,        35%
  website or a hotline.                                           

  Active education increase; e.g. training and visits by public   28%
  health professionals.                                           

  Grants or other financial assistance for improving CEH of       17%
  childcare.                                                      

  Cleaners and bleach concerns.                                   22%

  Air quality concerns:                                           21%

  Playground safety concerns:                                     7%
  --------------------------------------------------------------- ---------

The next childcare related phases of this project are to analyze the
data gathered, create a morbidity report on children's health in King
County, and to develop policy.

***Stakeholder Interviews***

Initial piloting of the stake holder interview shows that we have an
effective tool which augments networking. It will allow us to collect
and organize information on: funding, issue identification, and other
aspects of developing a comprehensive approach to CEH. Some themes which
came out in the pilot were ambient air concerns, upstream management
needed for chemicals, and a definite desire to have a more collective
and comprehensive approach to CEH.

***Strategic Planning Linkages***

Two of the fellows participated in the LHWMP strategic planning process
during 2006. The fellows looked for congruency between that program and
an overall CEH program. Resources were reallocated with new emphasis
placed on CEH. LHWMP has committed four staff equivalents to CEH. An
additional staff person has been dedicated to support policy development
using Precautionary Principle components, many of which are directly
linked on CEH issues. Below are some planned outcomes which were created
during the process.

-   By the end of 2007, a regional Children's Environmental Health
    Coalition is created.

-   By the end of 2007, create and pilot a plan that specifically
    targets pregnant women, parents and caregivers of children ages 0-6

-   By the end of 2007, a plan for reducing environmental health risks
    in King County childcare facilities is developed.

-   By the end of 2007, a report of compiled information is completed
    that assesses linkages between chemical exposure associated with
    childhood and the occurrence/incidence of disease

# NEXT STEPS:

## 

## **Explore Funding**

-   Continue interviews (good source of funding ideas)

-   Examine and report on strategies in existing programs

-   Link to new public health funding bill

-   Inventory funding sources for current activities

-   Draft three funding proposal for King County

## **Continued Problem Analysis**

### Reporting

#### Apply findings of Child Care Assessment

#### Develop report on local health determinants (this process has been work planned)

-   Identify needed research

    -   Modify based on partner / stakeholder

#### Gaps and overlaps

-   Stakeholder interviews

## **Continued Program Design**

### Examine other CEH programs

#### Compatibility / incompatibly with King County

-   Funding system

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-   For NW regional health determinants of concern

#### Continue Logic Model updates

-   Stakeholder interviews

## **CEH Activity Coordination**

### Increase Current Stakeholder involvement

### Develop new linkages

### Create advisory panel

### Regional newsletter

### Update inventory of CEH activities within PHSKC 

# LEADERSHIP DEVELOPMENT OPPORTUNITIES:

####### ***Peter Isaksen***

I would like to thank EPHLI for the opportunity to experience my
Fellowship year. I have learned so much more than I ever suspected. The
relationships with the other Fellows will be a constant memory that I
will cherish. The Mentors have been engaged, interested, helpful,
approachable, instructive and inspiring. The Institute staff has been
supportive, professional, outstanding, hard working and wonderful. The
best part of the entire year was learning so very much about myself.
When I first signed up for the Institute, I thought the most important
thing for the year would be the project. I suppose that was correct in a
way, especially if one thinks of the project as one's self. I learned so
many valuable lessons about how my and other people's minds work and
this will help me in all aspects of the rest of my life. I feel very
well prepared to take on additional responsibilities and look forward to
contributing at a high level for the protection of the Public's Health.

####### ***Jefferson Ketchel***

The EPHLI experience has changed the course of my Environmental Public
Health career. For years I have been focused on local issues and views,
unconnected with the larger, national perspective. This fellowship has
built bridges for me, not only to wonderfully inspiring colleagues from
around the country, but to the national role of the CDC in local
Environmental Public Health. EPHLI has taught me how to think
differently about solutions and challenges, looking at causality and
root problems instead of reaction based activities and the status quo. I
am proud to be a member of this fellowship and I hold a deep
appreciation to those who invited me into this arena and pushed me along
this past year. The lessons and ideas learned here shall carry me where
I now want to go, and the friends I have made will always be my network
of peers, ideas and Environmental Public Health dreams.

####### ***Tracee Mayfield***

My perception of the endeavor of public health has been irrevocably
changed. Before attending the program, public health was to me an odd
collection of local services, continuously struggling to adapt in
response to unforeseen and newly manifested changes in community health
problems. Chronically, community resources seemed too meager to invest
into long term, source mitigating solutions.

I still see the presence of formidable environmental problems; but now
these problems are at a global scale to me. Public health is a large
team (but also a small family), pooling resources, experiences and
knowledge together in a collaborative manner which echo's the children
story of stone soup.

The Environmental Public Health Leadership Institute has given me not
only the tools with which to work but also the ability to bring others
into the effort of addressing public health problems.

# ABOUT THE EPHLI FELLOWS

***Peter Isaksen***

Peter did not start his Public Health career until he had spent many
years in the restaurant business and also two years commercial fishing
in Alaska and Washington State. Along the way he received a Bachelor of
Science Degree in Microbiology from the University of Washington in 1984
and finally another Bachelor of Science Degree in Environmental Health
in 1991. After an internship at the Tacoma Pierce County Health
Department, Peter was hired there in 1991 to conduct a superfund related
creek study in which he was first introduced to mapping. Those maps were
created by hand lettering on acetate plastic for later printing. He has
been trying to map things ever since. In 1993 Peter was hired full time
at Public Health -- Seattle & King County as an Environmental Health
Specialist. He has worked in many different aspects of Environmental
Public Health through the years including inspecting On Site Sewage
Systems, Water Systems, Food Establishments, Schools and Pools. His
current position is in the Site Hazard Assessment Program where he
researches, samples and ranks Hazardous Waste Sites in King County. But
his true love is Geographic Information Systems (GIS). Peter is the
resident GIS guru for all of the Environmental Health Section and spends
a significant portion of his time advocating for and producing digital
maps of Environmental Public Health activities. If you have lots of
time, ask him about it!

***Jefferson Ketchel***

Jefferson Ketchel, RS is currently the interim operations supervisor for
the Local Hazardous Waste Management Program in the Environmental Health
Division at Public Health -- Seattle & King County (PHSKC). Mr. Ketchel
holds a Bachelors of Science in Biology with a Minor in Chemistry from
Central Washington University. He is currently pursuing his Masters of
Arts in Policy Studies at the University of Washington. For the past
twelve years, Mr. Ketchel has been employed at PHSKC being fortunate in
having diverse experiences while working in most of the available
programs including: food safety, water recreation, onsite sewage,
chemical/physical hazards, plumbing, vector/nuisance and hazardous
waste. When not engaged in school or his career, he enjoys Seattle
Seahawks football, the Olympics and stage acting in community theatre.

***Tracee Mayfield***

Tracee Mayfield is the father of two daughters, an avid fly fisherman,
and a home remodeling enthusiast. He gained both a United States Army
commission and an undergraduate degree from the University of Washington
where he studied environmental health under Chuck Treser. He is
currently pursuing a Masters in Public Health in Policy Analysis with
the Kirksville School of Osteopathic Medicine.

He currently works on policy development, integrating the Precautionary
Principle into local policy operations with the Local Hazardous Waste
Management Program, in the Environmental Health Division at Public
Health -- Seattle & King County (PHSKC).

# REFERENCES

1.  Children's Health Protection Web Page, USEPA,
    <http://yosemite.epa.gov/ochp/ochpweb.nsf/content/homepage.htm>.

2.  Senge, Peter, Art Kleiner, Charlotte Roberts, Richard Ross, Bryan
    Smith, *The Fifth Discipline Fieldbook,* 1994, Doubleday, New York,
    New York.

3.  10 Essential Public Health Services,
    <http://www.cdc.gov/nceh/ehs/home/HealthService.htm>

4.  CDC Health Protection Goals, CDC,
    <http://www.cdc.gov/about/goals/default.htm>

5.  National Strategy to Revitalize Environmental Public Health
    Services, CDC,
    <http://www.cdc.gov/nceh/ehs/Docs/nationalstrategy2003.pdf>