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Information sources typically include interviews in-person or via telephone ; site-specific investigation reports prepared by EPA, other federal agencies, and state, tribal, and local environmental and health departments; and site visits. Gathering pertinent site information requires a series of iterative steps, including gaining a basic understanding of the site, identifying data needs and sources, conducting a site visit, communicating with community members and other stakeholders, critically reviewing site documentation, identifying data gaps, and compiling and organizing relevant data to support the assessment.

Critical to the public health assessment process is evaluating exposures. One component of this evaluation is understanding the nature and extent of environmental contamination at and around a site. During this step, described in detail in Chapter 5 , you will evaluate the environmental contamination data obtained to determine what contaminants people may be exposed to and in what concentrations.


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As part of this evaluation, you will be assessing the quality and representativeness of available environmental monitoring data and determining exposure point concentrations. This is an important way to ensure that any public health conclusions and recommendations for the site are based on appropriate and reliable data.

Assessment of Population Health Risks of Policies | Gabriel Gulis | Springer

In some cases, further environmental sampling may be recommended to fill a critical data gap. While sampling data are preferred for public health assessments, mathematical modeling techniques are sometimes used to estimate environmental concentrations either temporally or spatially see Section 5. Evaluation of environmental contamination data typically proceeds simultaneously with the exposure pathway evaluation.

During the exposure pathway evaluation, described in detail in Chapter 6 , you will evaluate who may be or has been exposed to site contaminants, for how long, and under what conditions. You will consider past, current, and potential future exposure conditions. The overall purpose of this evaluation is to understand how people might become exposed to site contaminants e. If all of the elements described above are identified, a completed pathway exists.

If one or more components are missing or uncertain, a potential exposure pathway may exist. For completed or potential exposure pathways, you will evaluate the magnitude, frequency, and duration of exposures.

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As you evaluate exposure pathways, you should constantly remind yourself: If no completed or potentially completed exposure pathways are identified, no public health hazards will exist. If, as a result of your evaluation, you conclude there are no exposure pathways, then you will not need to perform further scientific evaluation. You will, however, need to explain your rationale for excluding each exposure pathway you deem incomplete and should communicate the conclusion of an incomplete pathway to the public at the earliest point possible. Additional community concerns not related to potential exposure pathways may be addressed in the community concerns section of the written public health assessment or the public health action plan see Section 2.

When complete environmental or biologic data are lacking for a site, you may determine that an exposure investigation is needed to better assess possible impacts to public health. These exposure investigations, often conducted by ATSDR or cooperative agreement partners, may include environmental sampling, measurements of current human exposure e. The results of an exposure investigation are used to support the public health assessment process. Screening is a first step in understanding whether the detected concentrations to which people may be exposed are harmful.

The screening analysis, described in detail in Chapter 7 , is a fairly standard process ATSDR has developed to help health assessors sort through the often large volumes of environmental data for a site. It enables you to safely rule out substances that are not at levels of health concern and to identify substances and pathways that need to be examined more closely.

For completed or potential exposure pathways identified in the exposure pathway evaluation, the screening analysis may involve:. For those pathways and substances that you identify in the screening analysis as requiring more careful consideration, you and site team members will examine a host of factors to help determine whether site-specific exposures are likely to result in illness and whether a public health response is needed.

In this integrated approach, described in detail in Chapter 8 , exposures are studied in conjunction with substance-specific toxicologic, medical, and epidemiologic data. Through this in-depth analysis, you will be answering the following question: Based on available exposure, toxicologic, epidemiologic, medical, and site-specific health outcome data, are adverse health effects likely in the community?

You will be considering not only the potential health impacts on the general community, but also the impact of site-specific exposures to any uniquely vulnerable populations e. Upon completing the exposure and health effects evaluations, you will draw conclusions regarding the degree of hazard posed by a site described in detail in Chapter 9 —that is, you will conclude either that the site does not pose a public health hazard, that the site poses a public health hazard, or that insufficient data are available to determine whether any public health hazards exist.

After drawing conclusions which occurs throughout the public health assessment process , you will develop recommendations for actions, if any, to prevent harmful exposures, obtain more information, or conduct other public health actions. These actions will be detailed in a Public Health Action Plan, which will ultimately be part of the public health assessment document or possibly public health consultations you develop for the site, as described in Section 2.

Note that some public health actions may be recommended earlier in the process see Section 2. You may develop various materials during the public health assessment process to communicate information about the assessment. For example, the team may develop outreach materials, as described in Chapter 4 , to communicate the status and findings of your assessment to the site community.

Whether and when to produce these materials or advisories and in what format is up to the judgment of the site team and their management. At the end of the assessment process, you will prepare a report that summarizes your approach, results, conclusions, and recommendations. Sometimes, an assessment of a single issue at a petitioned site may evolve into a more multifaceted assessment that results in a PHA.

Regardless of the document prepared, the overall assessment process, as described in this manual, is generally the same. As stated earlier, during the public health assessment process, you will not only evaluate whether a site poses a public health hazard, but also identify public health actions. Actions may be recommended at any appropriate point in the assessment process. Some recommended actions may be initiated before the completion of the PHA, such as certain health education activities or efforts to obtain additional exposure data. Other actions may begin during the assessment process but end after the release of the PHA for a site e.

Community involvement continues to be important as you identify and communicate public health actions. Communicating the findings of your assessment in an organized, clear, and concise way is equal in importance to conducting a scientifically sound evaluation.

As you prepare a public health assessment document, you will make many choices about how to organize material within each section, how much detail to provide, whether to use a question-and-answer format in various sections, and so on. While ATSDR has developed the minimum requirements presented below to ensure consistency and completeness, the agency encourages health assessors to remain flexible while fulfilling these requirements. You should use the most appropriate site-specific approach, based on the knowledge, expectations, and information needs of your audience.

The suggested format provides a framework for documenting the findings of the public health assessment. Subsequent chapters provide more detail on the type of information that you may need to consider and include in each section of the document. Generally, PHAs include the sections and appendices described below.

Additional sections may be included as you judge appropriate if the information may be helpful in communicating the findings.

Human health risk assessments

The main body of the document should be long enough to fully address pertinent issues. Narratives should be concise and relevant to those issues. In addition to the main text of the document you must include the preparers of the report, references , and various appendices. While your text should be written as clearly and concisely as possible when relaying the findings of the assessment, the use of various technical terms will likely be unavoidable. You should, therefore, include a glossary of terms in all PHAs. As mentioned, you will need to assign a conclusion category to your site and the exposure situations evaluated.

Reducing health inequity is a function of two critical components: baseline risk and intervention coverage. Although McLaren et al. First, discriminating methods multivariate risk algorithms of assessing baseline risk allow us to quantify important differences between social groups.

The Public Health System

With non-discriminating methods used by Rose , the potential for health inequalities will falsely appear small or non-existent. Secondly, baseline risk is essential to assessing the potential for policies or interventions to reduce inequities.

The main advantage of multivariate risk prediction algorithms over older methods of baseline risk assessement is their improved ability to discriminate risk. Discrimination is defined as the ability to differentiate between those who are high risk and those who are low risk—or in other words distinguishing who will and will not experience the outcome. An algorithm with high discrimination does well at rank-ordering subjects in terms of likelihood of experiencing the event. Calibration or accuracy is another property of a risk algorithm that describes how well the predicted probability of disease closely agrees with the observed outcome.

Take a hypothetical example of a community of people where people will die of heart disease over the next 10 years. In an ideal setting, we would have a perfect ability to discriminate risk and can predict exactly which people will die. Because population risk is not at all diffused, we could then target only these people with preventive interventions, resulting in an extremely efficient and effective health strategy.

Targeting the remaining 99 people with an intervention, even if it was radical, would have no preventive benefit. In public health, we rarely have such a clear knowledge of risk, though our tools are improving. Twenty-five years ago, we had poor risk prediction tools and so heart disease appeared diffused. To achieve a reduction in heart disease, it appeared that programmes needed to target most of the population.

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Assessment of Population Health Risks of Policies

Today, risk prediction tools using multiple risk factors such as the Framingham algorithm can identify over a fold difference in heart disease risk between individuals in developed countries. Since the inequities are so large for heart disease in many populations, it may be that focused prevention and treatment could be more effective and efficient for reducing inequities than radical interventions that cover the entire population. For maximum benefit, however, health inequities in heart disease and elsewhere are usually best addressed using multiple interventions that include both high-risk and population strategies.

The use of predictive risk algorithms in population settings is fairly new, and several methodological challenges may contribute to their limited use. To encourage forward thinking and debate about how best to estimate population risk, we briefly discuss three of these issues here. Simple predictive measures such as age and self-reported weight and smoking have been shown to have discriminating power equal to that of detailed clinical data, often with improved accuracy. Clinicians are chiefly concerned about the discriminating property of a predictive risk tool, but predictive accuracy has proven to be equally important in our collaboration with population health planners.

The challenge, as Diamond outlined, is that discrimination and accuracy or calibration mathematically compete with each other. Another desirable application of population risk algorithms is to assess the contribution of individual risk factors including behavioural or social risks to predictive risk. Risk algorithms are ideal for re-estimating baseline risk under scenarios where individual risk factors are modified.

The Health Assessment Process and your community

However, there are important interpretive cautions to consider and it is challenging to combine aetiognostic and prognostic research methods. To the contrary, multivariate risk algorithms can be used to more accurately discriminate risk in any population, including low-risk groups, and can help describe the benefits of all preventive health strategies, including those that are radical or upstream. A high-baseline risk strategy does not mean it focuses on downstream or medical treatment. Software updated on 29 August from version Code for developers.

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