Transformative Education
for Health Professionals

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Environmental health determinants account for significant inequities in health

Environmental health determinants account for significant inequities in health

As part of the build up to the WHO co-hosted session 'Looking beyond health; broadening perspectives at the Prince Mahidol Conference, Julian Fisher (JF) was pleased to interview Professor Patricia Butterfield (PB), Dean of Nursing at Washington State University when she visited WHO Headquaters in Geneva.  









JF: Alignment is needed between educational institutions and the systems that are responsible for health service delivery. Sir Michael Marmot’s recent report ‘Working for health equity; the role of the health professional’ has a section dedicated to education and training: “A greater focus on information about the social determinants of health, and information on what works to tackle health inequities, should be included as a mandatory, assessed element of undergraduate and postgraduate education.” 

  • Do you think there a need to address environmental sustainability / environmental health in a dual manner; as stand alone issue, but at same time as an integral part of health, noting call for specific health development goals eg reducing burden of main NCDs (WHO NCD Global Action Plan)
  • Would a definition for the 'environmental determinants of health’ help in this respect ?

Butterfield input:  Yes, outstanding idea.  Environmental health determinants account for significant inequities in health.  There is obvious overlap between social and environmental determinants of health; however they are not synonymous.  In some situations, historic conditions (mines, foundries, old housing) or ambient conditions (e.g., air or water pollution affecting all) lay the foundation to expose people from all socio-economic backgrounds to environmental health risks.  However in other situations, it is clear the environmental risks originate from social inequities; examples of such situations include the preferential placement of industrial facilities in low-income neighborhoods. 

JF:Noting environment – health linkages and commonality in terms of the need for a multi-sectoral approach (SDHA), for example to address climate change in health care settings, how might a shared ‘modifiable risk factors ‘ approach to prevention act as a both bridge and shared entry point for health professional education and training with regard to SDH ?

Butterfield input:  I also like this approach.  From my vantage point, health professionals often struggle with differentiating between modifiable and non-modifiable risk factors.  If they have a deep understanding of modifiable risks, they are able to exert the greatest impact on health outcomes.


'Prevention' for perspective of WHO healthy hospitals, health planet, health people' ( and WHO Global Action plan for noncommunicable diseases (

JF; Do you think education and training for SDH remain optional or be mandatory part of health professional education and training?

Butterfield input:  I can’t say because I don’t control purse strings in more than my own organization.  However I can advocate for the importance of SDH; without a working understanding of this perspective, clinicians will continue to react and response to illness occurrence, rather than seeing that the roots of illness are inherently tied to socio-economic factors. 

JF: Are there key elements of SDH education that you feel should be included in pre-service health professional education and training?

Butterfield input:  I think basic information of the SDH needs to be included in pre-health professional education.  Here’s why; sometimes we see clinicians that only understand a decontextualized world…..not seeing the web of causation between diabetes, obesity, fatigue, fast food, shift work, etc.  If pre-health professional students, gained this understanding early on, before they enter clinical practice, they would be able to see and understand that illness is often the result of social disparities rather than the antecedent. 

JF: which sources did you draw upon in developing competences for SDH teaching? which were most helpful and why ?

Butterfield input:  We have used the typical public health and community health nursing textbooks for our students as well as journal articles.  However we are turning much more to case studies, laying out this complexity for students.  In our area, we have focused on situations nearby (e.g., Libby, Montana asbestos contamination). 

JF: is the community empowered to play a role in curriculum development in your institution ? if yes who are the conduits ?

Butterfield input:  Yes and no.  We have very capable partners at our Regional Health District; however they have faced funding cutbacks.  As a result, sometimes we have empowered partners in the community who are not able to participate in joint initiatives fully because they have lost staff members due to budget cuts or program reductions. 

JF: Are there existing frameworks that we could support health profession education and service delivery, for example International Classification of functioning, disability and health (ICF) ?

Butterfield input:  I don’t know.  In regard to classifications, we use CDC information quite a bit.  In regard to conceptual frameworks, I really like Briggs ME-ME (multiple exposures-multiple effects) framework.  It is a WHO document.  His approach is simple for students to understand; very clear.  It’s not a SDH perspective approach per se, rather he looks at the way that persons’ exposure to multiple factors throughout their lives (e.g., cigarette smoke, asbestos, poor water quality, substandard diet) has multiple disease consequences later in life. 

JF: What have been your experiences in terms of curriculum development for environmental health / social determinants of health (SDH) ?

  • In your institution / country, do you consider that regulatory mechanisms and accreditation requirements facilitate or constrain curriculum development for SDH ?

Butterfield input:  We have done a lot in developing environmental health curricula, and I’m happy to share powerpoints or other materials with you.  In regard to social determinants of health, I have less information. 

In regard to our CCNE accreditation (Commission on Collegiate Nursing Education) in the U.S., we are required to provide students with content in the Baccalaureate “Essentials” document.  Here’s a link to this document; standard 7 addresses population health.

JF: did faculty leadership play a significant role in curriculum adaption ? what were some of the critical success factors ?

Butterfield input:  Generally our faculty are good at keeping up with current expectations regarding curricula.  Our curricula are, like many other disciplines, overcrowded and I do not think that SDH gets the level of attention it deserves. 


JF; Thank you Dean Butterfield, 


Patricia Butterfield is the Dean of Nursing at Washington State University. She is a public   health nurse with expertise in environmental health interventions, rural environmental health, and household level environmental contamination.  She has a Master of Science degree from the University of Colorado Health Sciences Center and a PhD in Nursing from Oregon Health and Science University (OHSU).  Her postdoctoral work was completed at OHSU’s Center for Research on Occupational and Environmental Toxicology.  She recently chaired a taskforce for the American Association of Colleges of Nursing focusing on environmental sustainability in US Colleges of Nursing.  Dr. Butterfield received NIH funding to conduct the nation’s first randomized controlled trial addressing an environmental health intervention delivered by rural public health nurses.  She has authored numerous papers addressing environmental health; Patricia is also the author of “Upstream Thinking,” a seminal nursing theory paper widely read within nursing and public health.