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A Framework for Integrating Environmental and Occupational Health and Primary Care in a Postdisaster Context

Kirkland, Katherine DrPH; Sherman, Mya MA; Covert, Hannah PhD; Barlet, Grace MPH; Lichtveld, Maureen MD, MPH

Journal of Public Health Management and Practice: November/December 2017 - Volume 23 - Issue - p S71–S77
doi: 10.1097/PHH.0000000000000656
Practice Reports: Practice Full Report

Context: Integration of environmental and occupational health (EOH) into primary care settings is a critical step to addressing the EOH concerns of a community, particularly in a postdisaster context. Several barriers to EOH integration exist at the physician, patient, and health care system levels.

Program: This article presents a framework for improving the health system's capacity to address EOH after the Deepwater Horizon oil spill and illustrates its application in the Environmental and Occupational Health Education and Referral (EOHER) program. This program worked with 11 Federally Qualified Health Center systems in the Gulf Coast region to try to address the EOH concerns of community members and to assist primary care providers to better understand the impact of EOH factors on their patients' health.

Implementation: The framework uses a 3-pronged approach to (1) foster coordination between primary care and EOH facilities through a referral network and peer consultations, (2) increase physician capacity in EOH issues through continuing education and training, and (3) conduct outreach to community members about EOH issues.

Evaluation: The EOHER program highlighted the importance of building strong partnerships with community members and other relevant organizations, as well as high organizational capacity and effective leadership to enable EOH integration into primary care settings. Physicians in the EOHER program were constrained in their ability to engage with EOH issues due to competing patient needs and time constraints, indicating the need to improve physicians' ability to assess which patients are at high risk for EOH exposures and to efficiently take environmental and occupational histories.

Discussion: This article highlights the importance of addressing EOH barriers at multiple levels and provides a model that can be applied to promote community health, particularly in the context of future natural or technological disasters.

Association of Occupational and Environmental Clinics, Washington, District of Columbia (Dr Kirkland and Ms Barlet); and Center for Gulf Coast Environmental Health Research, Leadership and Strategic Initiatives (Ms Sherman and Dr Covert), and Department of Global Environmental Health Sciences (Dr Lichtveld), Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana.

Correspondence: Mya Sherman, MA, Center for Gulf Coast Environmental Health Research, Leadership and Strategic Initiatives, Tulane University School of Public Health and Tropical Medicine, 1440 Canal St, Ste 2100, #8360, New Orleans LA 70112 (msherman1@tulane.edu).

The Gulf Region Health Outreach Program was developed jointly by BP and the Plaintiffs' Steering Committee as part of the Deepwater Horizon Medical Benefits Class Action Settlement, which was approved by the U.S. District Court in New Orleans on January 11, 2013, and became effective on February 12, 2014. The Outreach Program is supervised by the court and is funded with $105 million from the Medical Settlement.

The authors declare no conflicts of interest.

In the aftermath of the Deepwater Horizon (DWH) oil spill, Gulf Coast residents raised concerns about how the months-long spill might have affected their health. People were worried about air quality, coming into physical contact with dispersants and oil, and whether Gulf seafood was safe to eat. Questions were also raised about the psychological impacts of the spill.1 , 2 Researchers partnered with community members to investigate these issues,3–5 but there still remained a need to clinically address the environmental and occupational health (EOH) concerns in the region. As a result, a project was initiated to try to address the EOH concerns of community members and to assist primary care providers (PCPs) to better understand the impact of EOH factors on their patients' health.

Integration of EOH into primary care settings is an essential step to addressing the EOH concerns of a community, particularly in a postdisaster context. Community members who are at increased risk for suffering from EOH issues are often unaware or unwilling to connect health concerns to environmental or occupational hazards,6 increasing the importance of primary care physicians' ability to appropriately screen for EOH concerns and provide appropriate treatment, referrals, and education surrounding EOH issues. By taking EOH histories at routine visits, PCPs, which include physicians, nurse practitioners, and physician assistants, have the potential to recognize EOH conditions, flag environmental and occupational causes of disease, and help protect other workers and community members with similar exposures.7 PCPs can also act as important EOH resources for patients and other medical practitioners.6 , 7

There is some evidence of successful EOH integration with primary care. For example, the Migrant Clinicians Network (MCN) integrated EOH into primary care in 10 member clinics between 2006 and 2011. In addition to intensive EOH training for clinicians, MCN provided culturally appropriate educational materials for patients and community members with a focus on pesticide exposures. MCN found that with busy clinicians and a migratory workforce, a clinical “champion” who strongly believed in the importance of EOH issues was needed as well as significant support from MCN's occupational and environmental division.8

However, several barriers to EOH integration in primary care settings still exist at the physician, patient, and health care system levels. Evidence suggests that PCPs do a poor job of obtaining environmental and occupational histories and recognizing EOH conditions, in part due to the lack of EOH training most PCPs receive in medical school.6 , 9–11 EOH integration in primary care settings is also constrained by PCPs' competing demands and limited time to ask their patients about environmental or occupational exposures,12 as well as a national shortage of EOH specialists.9 , 13 The Accreditation Council for Graduate Medical Education, the body responsible for accrediting the majority of graduate medical training programs, does not recognize a specialty in environmental medicine. As such, board certification in occupational medicine is one of the recognized surrogates.14 Occupational medicine specialists have training in toxicology, low-dose chronic exposure, and population health. Unfortunately, there are a limited number of board-certified occupational physicians in the United States.14

In medically underserved areas, such as the Gulf Coast region, the shortage of PCPs and significant health disparities increase the difficulty of addressing EOH conditions.15 The Gulf Region Health Outreach Program (GRHOP), which funded this project, focused on the 4 Gulf states of Louisiana, Mississippi, Alabama, and Florida. None of these states had sufficient PCPs in 2013, and these states are projected to have between 17% and 33% fewer PCPs than patient demand in 2025.16 Misperceptions and limited knowledge of environmental risk at the community level are also important barriers to addressing EOH issues.17 , 18 Patients might not perceive an environmental exposure as a health risk unless the topic is discussed by a physician.19 Increasing environmental health literacy in the public has the potential to increase community resilience and improve health outcomes by enabling individuals to make more informed decisions about how to effectively reduce possible environmental exposures.18

In response to these multifaceted challenges, the Association of Occupational and Environmental Clinics (AOEC) partnered with the Environmental Health Capacity and Literacy Project at the Center for Gulf Coast Environmental Health Research, Leadership and Strategic Initiatives at the Tulane University School of Public Health and Tropical Medicine (Tulane) to work with a number of Federally Qualified Health Centers (FQHCs) in the Gulf Coast region to try to address the EOH concerns of community members and to assist PCPs to better understand the impact of EOH factors on their patients' health. Both AOEC and Tulane specifically worked with the FQHCs that were participating in GRHOP's Primary Care Capacity Project, led by the Louisiana Public Health Institute, to build on existing primary care capacity development efforts.20 In this article, we develop a framework for improving the health system's capacity to address EOH after the oil spill and present a case study of its application using the Environmental and Occupational Health Education and Referral (EOHER) Network.

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Framework for EOH Integration in a Postdisaster Context

The overall goal of the EOH integration framework is to improve the integration of primary care and environmental and occupational health care in the Gulf Coast. To address barriers to EOH integration at the health care system, physician, and community levels, the framework uses a 3-pronged approach to (1) create a referral network for referring patients to an EOH medical specialist, including peer consultations with an EOH expert, (2) provide continuing education (CE) and training for health care professionals to evaluate individuals with EOH complaints, (3) conduct outreach to community members about EOH issues (Figure). This framework considers the need to evaluate individual patients for EOH issues, as well as address key barriers to EOH integration within the health care system, including community misunderstanding of environmental and occupational exposures, insufficient EOH training among health care professionals, and limited coordination between EOH specialists and PCPs.

FIGURE

FIGURE

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Framework Application in the EOHER Program: A Case Study From the Gulf Coast

In the following sections, we present the application of the EOH integration framework in the Gulf Coast through the EOHER program.

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Referral network for EOH clinical evaluations

The referral network requires that a patient with an EOH concern must first be seen by a PCP at one of 11 participating FQHC systems. The PCP may then refer the patient to the EOH clinician designated by AOEC for that region. The appointment with the EOH clinician includes a full EOH evaluation (ie, history, physical examination, and testing) by a board-certified occupational physician. The costs of additional evaluation, either by a specialist (eg, in dermatology or pulmonary medicine) or for specialized testing (eg, magnetic resonance imaging), are also covered under the EOHER program if deemed necessary. Following the EOH workup, the patient receives a letter explaining the findings of the evaluation. The referring PCP is provided a full report, including any laboratory or radiographic results and recommendations for follow-up and/or treatment. If follow-up is required, the patient is referred back to his or her PCP for treatment, as the referral network does not pay for treatment.

To further strengthen the links between PCPs, EOH specialists, and community members, the EOHER program also offers free peer consultations where PCPs can contact AOEC or the EOH specialist for advice about EOH issues. Clinic staff and community members have also been provided with educational materials developed by AOEC, AOEC staff contact information, the AOEC Web site, and information about the Pediatric Environmental Health Specialty Units. AOEC staff members also made more than 30 trips to the Gulf Coast to discuss EOH issues with clinic staff and community members from 2013 to 2016.

As of December 31, 2016, data were available on 226 individuals evaluated under the referral network (Tables 1 and 2). The patients' main self-reported exposures included ergonomic/physical factors, crude and diesel oils, oil dispersants, and slips, trips, or falls. The primary diagnoses were musculoskeletal pain and respiratory issues, about half of which were upper respiratory tract infections. Since the exposures were all self-reported and the exposure pathways necessary for understanding long-term toxicologic effects were not established, we cannot infer any association or causation between the DWH oil spill and these diagnoses. To date, no physician-confirmed health conditions have been associated with potential exposure to the oil spill.1 , 2 , 15 , 21 , 22 Moreover, most of the physicians' diagnoses are considered preliminary, as data were submitted to AOEC after the initial visit with the EOH provider. However, these data do provide a useful baseline for EOH status and demonstrate the utility of using a referral network. Notably, trends in diagnoses and self-reported exposures varied substantially between clinic sites. For example, musculoskeletal pain was a predominant diagnosis at an urban clinic, where self-reported exposures related to ergonomic/physical factors. In contrast, contact dermatitis was a predominant diagnosis in a more rural clinic, where self-reported exposures related to crude oil and oil dispersants. These differences could reflect variations in livelihoods among the patient populations, with the latter clinic mainly serving those working in the fishing industry.

TABLE 1

TABLE 1

TABLE 2

TABLE 2

There was a drop-off in EOH evaluations in 2016. This trend potentially reflects the length of time passed since the spill occurred and that PCPs in the referral network are now better equipped to evaluate and treat EOH issues after becoming familiar with the diagnoses and treatment plans recommended by the EOH specialists in the network. It is also possible that EOH concerns were exaggerated in the aftermath of the oil spill and actual demand for EOH treatment was consequently lower than expected. Potential misperceptions of environmental exposure can occur after a disaster, largely due to biased and sensationalized media coverage of the event.17 , 18

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Continuing education for health care professionals

Eight online EOH educational modules for health professionals were developed through the EOHER program to fill the need for continuing medical education (CME) and CE (see http://www.gulfcoastenvironmentalhealth.com/CME-credits). Modules were developed by experts from institutions around the country, including Yale University, University of Illinois–Chicago, and University of California–San Francisco, in response to a competitive Request for Proposals. These modules are available for CME/CE credit and can be accessed for online self-instruction or can be presented in person by AOEC staff or affiliate clinic members. Staff members employed at any of the participating clinics who complete the modules may be reimbursed for the cost of their CME/CE certificates through the EOHER program. The modules address the most frequently mentioned environmental issues raised during community interactions that are potentially related to health concerns, such as benefits and risks of seafood consumption, reproductive health effects of the oil spill, the airborne and dispersant exposures and health effects of the oil spill, and taking an EOH history. AOEC has provided tailored in-person education to more than 400 clinical staff members on topics covered in the modules as well as other topics (eg, ergonomics) at FQHCs, conferences, medical schools, and retreats for clinical staff members.

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Community outreach

After the DWH oil spill, many community members reported lacking the necessary information needed to make informed decisions regarding seafood consumption, which was exacerbated by a lack of trust in regulatory agencies as a primary source of information.17 To address this and other EOH concerns, AOEC staff members have participated in outreach efforts to engage community members in 16 of the 17 designated Gulf Coast counties and parishes affected by the oil spill. A conservative estimate of the number of community members reached since 2013 is more than 800. Most of these interactions took place at health fairs, small group discussions, and meetings with local trade associations. Community outreach highlighted key areas of community concern, including safe seafood consumption for pregnant women, air pollution, pediatric asthma, and cancer risk from working on the oil cleanup. The community concerns reported through outreach have driven the development of CE modules, informed clinicians about their patients' concerns, and directed the development of educational resources and outreach efforts.

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Successes and Lessons Learned From Framework Implementation

The implementation of the framework in the Gulf Coast highlighted important practical insights into EOH integration in a postdisaster context. All 3 components of the program were implemented concurrently. However, establishing the referral network at the onset of the program was fundamental for connecting CE efforts to the network of physicians and providing community members information on referrals and services available in the participating FQHC systems. Accordingly, one of the first tasks for the EOHER program was to begin establishing the referral network in 2012 (when GRHOP funding became available) by identifying board-certified occupational physicians in each of the 4 states that would accept referrals from the participating primary care clinics. This task was complicated by the lack of EOH expertise in the region. Just 90 board-certified physicians were located throughout Louisiana, Mississippi, and Alabama,23 and even fewer were located in the affected counties and parishes. Ultimately, AOEC signed contracts with 6 occupational health providers along the Gulf Coast (2 in Louisiana, 2 in Alabama, and 1 each in Mississippi and Florida) who would accept referrals from PCPs. Once the referral network partnerships were established, AOEC began conducting community outreach. While the referral network was being finalized, the CE modules were also being developed. The first CE module became available in 2013, and subsequent modules were developed annually thereafter.

PCPs in this program did not take full advantage of the CE or the EOH referral network. Given the limited time available for individual patient visits, adding in multiple additional questions about EOH concerns to a patient visit was problematic for providers.24 The workload at the FQHCs also limited the time providers could take for educational activities, resulting in few CME certificates being awarded through the program. Clinicians indicated that they were more inclined to take CE courses directly pertaining to their specialty and as part of another activity, such as professional meetings or on-site at clinic facilities. To overcome these challenges, AOEC worked extensively with individual clinicians and clinics to foster buy-in for integrating EOH questions in patient visits. For example, the AOEC team expanded the options for completing the CE courses by providing in-person instructional sessions in a variety of settings, including meetings for clinic staff members, Grand Rounds, and lectures for medical students and residents. As a result of these additional efforts, the leadership at several of the FQHCs began to actively reach out to the AOEC team for referral services and education. The success of these clinics' engagement in the program reflected the clinics' ability to articulate the EOH-related needs of the organization and client population, as well as the EOHER program's ability to respond quickly to clinic requests and tailor educational content to clinic needs.

Issues surrounding trust and financial resources constrained community member participation in the EOHER program. Discussions at community meetings and focus groups indicated that some fisherfolk in the region felt that being evaluated under the EOHER program would jeopardize any ongoing or future lawsuits they might have related to the spill. Certain ethnic populations were worried about encountering prejudice from clinic staff members. AOEC overcame some of this distrust at one site after multiple meetings with community members. In this case, developing strong rapport with a local trade association resulted in an additional 16 individuals making appointments for an EOH evaluation within 3 weeks of meeting with AOEC. A total of 24 individuals from this community received an EOH evaluation. Language and limited insurance coverage were also barriers for the primary care referral in the program. Although the FQHCs had sliding scale visit fees, there was still a cost involved for anyone to be seen by a PCP, which was a prerequisite to receive an EOH referral. Concerns regarding potential co-pays were raised as an issue in one community. In addition, while there were referral clinics in each of the 4 states, the EOHER program was unable to provide referral clinics in close proximity to all of the referring FQHC sites due to the limited number of board-certified occupational specialists in the region. As a result, travel times to the occupational clinics could be lengthy. While the EOHER program could cover transportation costs for all patients, only 2 patients took advantage of this option. Receiving a PCP referral to the EOH specialist posed a potential barrier for some patients; yet, this program feature was important to build EOH capacity among PCPs and primary care clinics and to ensure that patients were not being referred for clinical evaluations that would ultimately be used for litigation purposes.

High organizational capacity and effective leadership were critical to the implementation of the EOH integration framework. AOEC as an organization was uniquely qualified to administer this program, given its expertise in clinical occupational and environmental medicine, commitment to collaborative research, education, and clinical outreach, as well as its extensive networks of academic and clinical institutions across the United States. AOEC also partnered with the Environmental Health Capacity and Literacy Project at Tulane's Center for Gulf Coast Environmental Health Research, Leadership and Strategic Initiatives, the direct recipient of GRHOP funding, to implement the EOHER program. The Center's mission is to advance environmental and reproductive health in the Gulf Coast's health disparate communities by implementing research and innovative interventions. The Center leveraged its research and administrative infrastructure, as well as faculty and practitioner expertise, to manage and provide oversight to the EOHER program. Both AEOC and the Center have experience working with vulnerable populations in the Gulf Coast and are skilled in tailoring program implementation to the local context.

Synergistic partnerships also enabled AOEC to expand the scope and enhance the impact of the EOHER program. For example, rapport was developed between AOEC and the staff from GRHOP's mental and behavioral health projects. The resulting discussions highlighted how many EOH health concerns do not have a clinical “cure” and introduced an understanding to the EOHER program of the need for mental and behavioral counseling on job limitations and/or job loss due to EOH. A separate project with Tulane led to some of the EOH CE modules being incorporated into the nursing curriculum at a local community college. In several instances, AOEC also worked as a liaison between communities, PCPs, EOH specialists, and stakeholder institutions. For example, as a result of the referral network, one of the participating FQHCs now rents space to an EOH physician for a satellite clinic. The resulting colocation of the EOH clinic and the primary care clinic has further embedded EOH in the primary health care system, enabling “hallway consultations” as well as formal referrals.

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Conclusions and Future Directions

In this article, we developed a framework for EOH integration in a postdisaster context and presented the application of this framework in the Gulf Coast through the EOHER program. Using a 3-pronged approach, AOEC provided education and/or outreach to more than 1250 health care professionals, clinic staff members, and community members and provided 226 clinical EOH evaluations for patients since 2013.

Overall demand for EOH referrals in the EOHER program was lower than originally expected, and some clinics in the EOHER program were more active in the referral network than others. The varying levels of participation among clinics could be related to patient demographics and varying levels of clinic capacity to address patients' EOH concerns. Lack of financial incentive to address EOH issues during patient visits has also been considered an important barrier to EOH integration.13 , 24 The EOHER program's ability to cover expenses associated with EOH evaluations and CME/CE certificates was thus an important and unique feature of this program.

The implementation of the framework in this case study highlighted many of the same barriers to EOH integration reported in the literature, including physicians' limited available time and competing patient needs.13 , 19 , 24 Establishing a robust evaluation system to assess framework implementation is thus critical for refining EOH integration strategies over time. Accordingly, the next steps for the EOHER program will be to collect data from the physicians in the referral network to measure program outcomes, including the number of patients who do not follow up with the EOH specialist after receiving a referral from their PCP.

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Implications for Policy & Practice

  • This article presents a framework to address EOH issues in the aftermath of the DWH oil spill, providing a model that can be applied to promote community health, particularly in the context of future natural or technological disasters.
  • The framework highlights the importance of addressing barriers to EOH integration at the patient, physician, and health care system levels.
  • Physicians in this article were still constrained in their ability to engage with EOH issues due to competing patient needs and time constraints, indicating the need to improve physicians' ability to assess which patients are at high risk for EOH exposures and to efficiently take environmental and occupational histories.
  • This article also revealed the importance of providing EOH CE to health care professionals through multiple mediums, including online and in-person trainings outside of the CME structure.

While the scale of framework implementation is limited to select clinics in the Gulf Coast, these advances represent a major step toward EOH integration into primary care settings. It is, however, important to note that this framework was primarily developed for application in a postdisaster context, specifically the DWH oil spill, and may not be generalizable to all settings. AOEC also worked with clinics that were selected through GRHOP's Primary Care Capacity Project, potentially resulting in a baseline capacity to provide primary care services among participating clinics that might be lacking in other settings. However, there is a general need to train both EOH specialists and PCPs in environmental medicine10 , 13 and build community members' capacity to talk to their physicians about EOH issues,6 , 13 , 19 suggesting the potential to apply the framework in nondisaster contexts outside of the Gulf Coast.

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References

1. Solomon GM, Janssen S. Health effects of the gulf oil spill. JAMA. 2010;304(10):1118–1119.
2. Lowe SR, Kwok RK, Payne J, Engel LS, Galea S, Sandler DP. Why does disaster recovery work influence mental health? Pathways through physical health and household income. Am J Community Psychol. 2016;58(3/4):354–364.
3. Grattan LM, Roberts S, Mahan WT, McLaughlin PK, Otwell WS, Morris JG. The early psychological impacts of the Deepwater Horizon oil spill on Florida and Alabama communities. Environ Health Perspect. 2011;119(6):838–843.
4. Lichtveld M, Goldstein B, Grattan L, Mundorf C. Then and now: lessons learned from community- academic partnerships in environmental health research. Environ Health. 2016;15(1):117.
5. Wilson MJ, Frickel S, Nguyen D, et al A targeted health risk assessment following the Deepwater Horizon oil spill: polycyclic aromatic hydrocarbon exposure in Vietnamese-American shrimp consumers. Environ Health Perspect. 2015;123(2):152–159.
6. Politi BJ, Arena VC, Schwerha J, Sussman N. Occupational medical history taking: how are today's physicians doing? A cross-sectional investigation of the frequency of occupational history taking by physicians in a major U.S. teaching center. J Occup Environ Med. 2004;46(6):550–555.
7. Lax MB, Grant WD, Manetti FA, Klein R. Recognizing occupational disease: taking an effective occupational history. Am Fam Physician. 1998;58(4):935–944.
8. Garcia D, Hopewell J, Liebman AK, Mountain K. The Migrant Clinicians Network: connecting practice to need and patients to care. J Agromed. 2012;17(1):5–14.
9. Burstein JM, Levy BS. The teaching of occupational health in US medical schools: little improvement in 9 years. Am J Public Health. 1994;84(5):846–849.
10. Kilpatrick N, Frumkin H, Trowbridge J, et al The environmental history in pediatric practice: a study of pediatricians' attitudes, beliefs, and practices. Environ Health Perspect. 2002;110(8):823–827.
11. Trasande L, Schapiro ML, Falk R, et al Pediatrician attitudes, clinical activities, and knowledge of environmental health in Wisconsin. WMJ. 2006;105(2):45–49.
12. Morrow J. The role of local public health agencies in pesticide exposure. J Public Health Manag Pract. 2008;14(3):311–312.
13. Harber P, Merz B. Time and knowledge barriers to recognizing occupational disease. J Occup Environ Med. 2001;43(3):285–288.
14. American College of Occupational and Environmental Medicine. Board certification. What is OEM? http://http://www.acoem.org/BoardCertification.aspx. Published 2017. Accessed April 11, 2017.
15. Goldstein BD, Osofsky HJ, Lichtveld MY. The Gulf oil spill. N Engl J Med. 2011;364(14):1334–1348.
16. US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, National Center for Health Workforce Analysis. State-Level Projections of Supply and Demand for Primary Care Practitioners: 2013-2025. Rockville, MD: US Department of Health and Human Services; 2016:36.
17. Simon-Friedt BR, Howard JL, Wilson MJ, et al Louisiana residents' self-reported lack of information following the Deepwater Horizon oil spill: effects on seafood consumption and risk perception. J Environ Manage. 2016;180:526–537.
18. Finn S, O'Fallon L. The emergence of environmental health literacy—from its roots to its future potential. Environ Health Perspect. 2017;125(4):495–501.
19. Liebman AK, Rowland M. To ask or not to ask: the critical role of the primary care provider in screening for occupational injuries and exposures. J Public Health Manag Pract. 2009;15(2):173–175.
20. Brown L, Giepert JC, Black B, Farb H. Investing in local partners and peer-to-peer exchange to advance the bridging of public health with primary care across the Gulf Coast. J Public Health Manag Pract. 2018;(GRHOP spec issue).
21. Michaels D, Howard J. Review of the OSHA-NIOSH response to the Deepwater Horizon oil spill: protecting the health and safety of cleanup workers. PLoS Curr. 2011;4:e4fa83b7576b6e.
22. Kwok RK, Engel LS, Miller AK, Blair A, Curry MD, Jackson WB. The GuLF STUDY: A prospective study of persons involved in the Deepwater Horizon oil spill response and clean-up. Environ Health Perspect. 2017;125(4):570–578.
23. Meirs KW. Access to Physicians With Environmental Exposure Expertise in the Gulf of Mexico: Presence ≠ Access [Capstone Project]. Philadelphia, PA: Perelman School of Medicine, University of Pennsylvania; 2014.
24. Tai-Seale M, McGuire TG, Zhang W. Time allocation in primary care office visits. Health Serv Res. 2007;42(5):1871–1894.
Keywords:

capacity building; environmental health; environmental medicine; health education; professional education

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