Abstract
Background:
There is a robust correlation between environmental exposures and unjust cardiovascular outcomes among Black populations. Community-based public health nurses (CBPHNs) can effectively implement environmental justice interventions to promote heart health. A collaboration of interdisciplinary researchers and CBPHNs aimed to gain insights into local variables associated with these injustices for the purpose of informing CBPHN partnerships with Black residents to promote heart health.
Methods:
Using a community-based participatory action approach, a mixed-method survey explored the relationship between perceived environmental injustice, stress, and health among Black adults and their concerns about local environmental health hazards.
Results:
Community-based organizations supported the recruitment of a convenience sample (n = 203) of Black adults from small neighborhoods distributed across a midwestern city. Statistically significant relationships were found between perceived environmental injustices, self-reported stress, and health. Most participants believed that the environment affected their health. Participant concerns included their experiences of racialization and inequality, overexposure to environmental hazards, and unequal access to resources.
Discussion:
The determinants and effects of environmental hazards on heart health are well documented in the research literature. The implications for CBPHNs in promoting environmental justice and heart health in their practice and policy advocacy are discussed.
Conclusion:
The association between environmental injustice and heart health in Black communities is substantial. The findings support nurse–community partnerships to understand what is needed to promote health equity by implementing CBPHN strategies that recognize distinct factors that impact heart health among Black adults.
INTRODUCTION
Heart health is crucial in the overall context of public health, and it becomes much more significant when considering the specific experiences of the Black community. 1 Multiple studies have found definitively robust correlations between environmental exposures and inequalities in cardiovascular well-being among Black populations.2,3,4,5,6 Environmental health is defined as the “freedom from illness or injury related to toxic agents and other environmental conditions that are potentially detrimental to human health.” 7 Robert Bullard, widely considered the initiator of the contemporary environmental justice movement, noted that all people and communities are entitled to equal protection of environmental and public health laws and regulations. 8 Black communities are overexposed to racialized, disparate conditions, also known as environmental injustices, that lead to a higher incidence of cardiovascular disorders, emphasizing the urgent requirement for public health interventions.9,10 Public health nursing is defined as the practice of promoting and protecting the health of populations. 11 Community-based public health nurses (CBPHNs) practice in neighborhoods that experience unjust health outcomes and could, therefore, be effective facilitators of environmental justice interventions that promote heart health. There are a few examples of nurses addressing community-identified environmental justice issues.12,13 However, limited evidence supports nursing-specific best practices in this area. 14
This exploration focuses on the intricate dynamics of environmental injustices that influence heart health in the Black community of a midwestern city. Local county data show that the age-adjusted heart failure hospitalization rate per 10,000 people (2018–2020) for Black adults is almost five times higher (129.4) than the overall rate (26), and the death rate per 100,000 Black adults with heart disease is significantly higher (208.4) than the overall rate (125).15,16 Our collaboration of interdisciplinary researchers and local health department CBPHNs aimed to gain insights into the variables that cause these injustices. The CBPHNs address unjust population health outcomes and the social determinants of health (SDOH) by organizing to develop and implement public health interventions in partnership with communities.17,18,19 They have earned trust and built relationships over time with the communities they serve, predominantly Black and Latine. They form authentic partnerships with community members, use data and lived experiences to understand community health, connect individuals with resources and services, and promote population health equity. Overall, CBPHNs take a strength-based, collaborative approach to health promotion and disease prevention and support the needs and priorities identified by community members.
Previous neighborhood assessments by CBPHNs and other local public health staff uncovered resident concerns about pollution and noise from nearby major roadways, poor indoor housing air quality (e.g., pests, mold), and brownfields. However, these findings were not specifically focused on the experiences of Black residents, nor had they been explicitly recognized as environmental injustices correlated with public health outcomes, such as cardiovascular disease. Understanding Black residents’ perspectives on how environmental injustices affect their health is a first step toward informing actions to advance environmental justice and public health. 20 Our study had several aims and co-investigators who collected various data, such as physical activity, fruit and vegetable intake, spirituality, and pain. The aims focused on environmental justice included (1) understanding the relationship between perceived environmental injustice, stress, and health among Black adults and (2) understanding the environmental injustice concerns of Black adults. We developed a mixed-methods study to explore whether our partnership could support CBPHN community organizing, a common public health nursing strategy, 21 with the Black community by engaging residents in determining environmental justice and heart health priorities. 22
Theoretical frameworks
This study is based on the American Heart Association’s (AHA) Life’s Essential 8 model. 23 The AHA model describes the essential context of psychological health and well-being and the SDOH for maintaining or improving heart health. The SDOH provides the daily context for heart health and determines the potential for success or failure of interventions. This study also incorporates a critical lens with the Critical Environmental Justice Nursing for Planetary Health Framework (EJ Nursing Framework). 24 The EJ Nursing Framework applies critical theories to the way people conceptualize the root causes of environmental injustices as patterns of domination (e.g., supremacy and capitalism) and violence (e.g., state violence and ecocide) that produce patterns of health (e.g., despair, morbidity, and mortality).
METHODS
Using a community-based participatory action approach, a mixed-methods survey was used to explore the relationship between perceived environmental injustice, stress, and health among Black adults and to understand their concerns about environmental injustices. The survey’s environmental health and injustice questions were informed by research examining how racial identities, environmental attitudes, and experiences with discrimination affect perceptions of environmental justice and environmental injustice assessments with Black communities. 25
Study design and participants
The CBPHNs used their existing networks to assist with participant recruitment from community-based organizations (CBOs), including community health worker CBOs, grassroots CBOs led by the Black community, neighborhood associations, community-based programs in the county Human Services department, city programs addressing racial equity, and one-on-one interactions with community members at events or during the CBPHNs other work in the community. Participants completed an in-person health assessment and a cross-sectional online survey administered via laptop computers. Volunteers were eligible to participate in the study if they were 18 or older, English-speaking, and racially identified as Black or African American. Participants received one $25 gift card in remuneration. The study team implemented the informed consent process with each participant, and the research complied with the current ethical guidelines. The study underwent evaluation and received approval from the Institutional Review Board at the University of Wisconsin-Madison.
Data collection
All data were collected over 6 months (2023) and then stored and organized using Qualtrics and Microsoft Excel. The study included n = 203 participants from the local Black community of a small midwestern city. Data collection procedures were performed by trained undergraduate nursing students who completed a required vital signs simulation module. Qualified nursing faculty and research team members supervised the students. Blood pressure was assessed using a standard protocol. Systolic blood pressure was used as a critical variable for this study because prior research has established systolic blood pressure as a more powerful predictor of blood pressure classification and risk level than diastolic blood pressure. 26 The students were trained to respond if a systolic blood pressure was outside the normal range (exceeding 130 or 140 mmHg). The survey included a demographic form and subscales on environmental injustice, environmental health, perceived stress, and overall health. An open question about environmental health hazards was included (see Supplemental File).
Health department CBPHNs provided a consistent presence during survey protocol administration, allowing for mutually beneficial engagement opportunities both pre- and post-survey completion. The CBPHNs welcomed participants and answered questions about the design and purpose of the study protocol. As study team members, CBPHNs helped create a safe, person-centered experience for all participants. Optional post-survey engagement allowed for unscripted nurse–participant dialogue driven by the participant, creating favorable circumstances for authentic interaction and trust-building.
Data analysis
Quantitative analysis
Linear regression was used to assess relationships between environmental injustice and environmental health on systolic blood pressure (a continuous outcome). Logistic regression assessed the relationships between environmental injustice and environmental health on self-rated stress (treated as binary) and self-reported health (treated as binary). Missing values were not imputed; instead, complete cases were only used. The decision to use complete cases rather than impute was based on a rate of <4% missingness. There were 195 complete cases out of 203 sampled individuals. The analysis was performed using RStudio 2023.031 Build 446 using tidyverse, 27 Table 1, 28 and sjPlot packages. 29
Participant Demographics
SD, standard deviation; GED, General Education Development; CI, confidence interval.
Qualitative analysis
Content analysis was used to describe and systematically quantify the qualitative data. 30 The previously described theoretical frameworks deductively guided the analysis of the qualitative survey question, “Name the environmental health hazard in your neighborhood that worries you the most.” The first three authors coded open-text responses, with two team members coding each response. The data analysis followed the recommended phases outlined by Elo and Kyngas (2008), including memoing (i.e., reading through the text, making margin notes, forming initial codes), describing (i.e., describing open codes in a codebook), classifying (i.e., developing higher-order categories), and representing (i.e., presenting categories in discussion). Deductive content analysis was conducted using Microsoft Excel.
RESULTS
The sample had a mean age of 46.7 (range: 18–81). Participants were primarily female (69.5%) (see Table 1 for demographics). The means for key variables are presented in Table 2.
Key Variables. Outcomes: Systolic Blood Pressure, Self-Reported Stress, Self-Rated Overall Health. Exposures: Total Environmental Injustice Score, Total Environmental Health Score (Only Complete Cases Are Included Here)
Total environmental injustice score
Regressions models (Table 3) for the exposure of interest use the total environmental injustice score. A high environmental injustice score indicates that the participant responses were “Strongly Agree” or “Somewhat Agree.” A low environmental injustice score indicates that participant responses were “Strongly Disagree” or “Somewhat Disagree.” Participants responded to three questions developed by the researcher: “Environmental injustice exposes Black neighborhoods to health hazards,” “Environmental injustice increases the rate of sickness in my neighborhood,” and “Environmental injustice in my neighborhood is stressful for me.” The regression analyses (Table 3) show that after adjusting for the effects of sex, age, education, income, and tobacco use, the relationships between environmental injustice and self-rated health and environmental injustice and self-reported stress remain statistically significant.
Environmental Injustice
Total environmental health score
In the regressions presented in Table 4, the exposure of interest is the total environmental health score. A high environmental health score indicates that participants “Strongly Agree” or “Somewhat Agree.” with the self-rating statement. In contrast, a low environmental health score indicates that participants “Strongly Disagree” or “Somewhat Disagree” with the following three statements: “The environment affects health,” “The environment affects my family’s health,” and “The environment affects my health.” At the 0.05 significance level, only the relationship between environmental health and self-rated current health status is statistically significant after adjusting for demographic covariates.
Environmental Health
Content analysis results
A total of 137 participants (68% of the sample) responded to the survey question, “Name the environmental health hazard in your neighborhood that worries you the most.” Participant responses were organized into three categories: racialization and inequality, overexposures, and unequal access to resources. The following narrative summarizes these results.
Racialization and inequality
Structural environmental injustices are often intertwined with systemic racialized discrimination and marginalization, more commonly referred to as environmental racism. 31 Eight participants explicitly stated racism as the environmental health hazard that worried them most. Exemplar:
Political environments. Racism. Judicial racism. Political racism against Black persons altogether. The U.S. ‘justice’ system, the COURT SYSTEMS and institutional racism are constantly ongoing and stressful towards Black people.
A participant noted that they are most concerned about “how Black men are attacked in the media, and it is considered normal.” Participants said they wanted to experience less racism, discrimination, micromanagement, and microaggressions. They described economic inequality as a structural injustice created by state violence and capitalism. Exemplar:
The environmental health hazard that worries me the most is economic inequality between African Americans and Whites/other races in this country. WE African Americans want spacious land, beautiful home, ample amenities, freedom from poverty and less racist toward us attitudes. These items should be in repayment for hundreds of years of unpaid, non-compensated labor, blood and life given to raise this country to its present stature!
A participant noted they were most worried about “The hazards of the government using modern day slavery with finances.” Other participants said their concern is having to struggle to meet everyday needs, “living paycheck to paycheck,” and the difficulty of obtaining a well-paid job.
Overexposures
Participants described their experiences of overexposure to multiple environmental hazards. Below are exemplars of resident concerns about overexposure to hazards related to land, air, water, climate change, and environmental racism:
Garbage hazard (smell and pollution).
Industrial pollution effecting air.
PFAS and other environmental injustices that impact BIPOC communities in regards to drinking water, fishing and recreational opportunities.
Climate change, it’s getting hotter all the time.
The piping and water system in the housing, water filtration system in buildings. The water is contaminated, better management on the properties where they place minorities would help the health hazard. I have noticed a big difference between the neighborhoods. There are noticeable differences between property management in water filtration system mainly, amongst other things.
Participants also expressed concerns about noise and heavy traffic. In addition to heat, climate change concerns focused on exposure to cold, flooding, and storms. Participants also described their overexposure to interpersonal and community violence (e.g., gun violence, crime, fighting, alcohol use, and overdoses) as the environmental health hazards that worried them most.
Unequal access to resources
Participants described how systems within SDOH negatively affected them. These systems included less access to healthy and affordable food, dignified housing, quality healthcare, safe schools, and greenspaces. A participant explained how these experiences become cumulative, “Jobs people have a hard time getting a job, school short staffing, hard time getting a home, and acquiring food, and all of these affect health.” Another said, “A lot of families are caught in this ugly web.” The prevalence of “mental health issues” and lack of accessible mental health providers were also noted. However, the health and well-being of “Young Black Children” was most commonly stated as a priority concern.
LIMITATIONS
The generalization of our findings is limited by sampling bias. The participating Black adults lived in communities dramatically impacted by local municipal policies, commuter highway traffic, food deserts, and few employment opportunities. Though not uncommon, these community experiences can create unique residential beliefs and perceptions. The study may not be able to represent the viewpoints and experiences of members of the Black community who are not involved with the CBOs we partnered with to recruit participants. Individuals not participating in CBOs may have different health practices, beliefs, and socioeconomic situations than those involved in community organizations. Finally, while the literature informed the survey development, further validity and reliability testing is required. Therefore, the findings of this study should be interpreted as “early findings,” with future research requiring surveys that have been tested for reliability and validity.
DISCUSSION
This study explored environmental injustice priorities and heart health in a Black community for evidence supporting real-world approaches to nurse–community partnerships. Study aims included (1) understanding the relationship between perceived environmental injustice, stress, and health among Black adults and (2) understanding the environmental injustice concerns of Black adults. We found statistically significant relationships between perceptions of environmental injustices and self-reported stress and health, as well as participants’ belief that the environment affects health and their self-reported health. Participant environmental health hazard concerns included their experiences of racialization and inequality, being overexposed to environmental hazards, and having unequal access to resources.
Our findings align with previous research, which illustrates how environmental injustices and the SDOH collectively impact stress and perceived health among Black communities. Chronic stress is known to have a detrimental effect on heart health. 32 We note that these factors were created through a complex process of redlining, a system of discrimination that governments and banks used for decades to financially disadvantage and isolate Black communities with dehumanizing neighborhood conditions. 33 Redlining became a reliable system of environmental injustices that all but eliminated greenspaces and overexposed generations to industrial waste and interstate highways. 34 It is well-documented that this environmental racism significantly influences the probability of exposure to pollution. 35 Exposures of this kind have been associated with a higher incidence of cardiovascular illnesses, such as hypertension and coronary artery disease. 36 As participants in our study noted, lack of access to high-quality healthcare exacerbates the adverse effects of environmental injustices on the cardiovascular health of Black communities. The disparities in healthcare access and outcomes, as demonstrated by Williams and Mohammed (2013) and Brown et al. (2019), indicate a significant shortcoming in the timely identification and management of cardiovascular ailments. 37 This heightens the burden of environmental stressors and contributes to unjust health outcomes.
The experience of being racialized, overexposure to pollution, and having decreased access to safe greenspace and high-quality healthcare contribute to a multifaceted narrative that leads to poor cardiovascular outcomes. 38 Our exploratory analyses clearly show the articulated environmental health concerns and priorities in a marginalized Black community, emphasizing the pressing need for CBPHNs to prioritize environmental injustice as a necessary step in advancing health equity. Preliminary findings were shared and discussed with community members, CBPHNs, and CBOs at a community meeting in August 2023. The CBPHNs are fully integrated into the communities they serve geographically and relationally. Therefore, CBPHN follow-up with the community regarding study results is ongoing with all the previously mentioned organizations and individuals who assisted with participant recruitment. The CBPHNs convene and collaborate with community members, private and public sector agencies, and across systems to elevate these concerns and priorities. This study’s findings can help guide meaningful conversations about improving air and water quality, increasing climate change resilience and access to resources, and decreasing environmental health hazards to improve heart health. For example, CBPHNs can share study results related to racialization and inequality with the city’s Racial Equity and Social Justice Initiative, which focuses on promoting racial equity in city operations, policies, and budgets. The city has also embarked on an air quality monitoring program. Using study results related to overexposures, the CBPHNs can advocate for air quality monitoring in their respective geographic areas. Public health staff are also involved in PFAS education in communities most impacted by the contaminants in the water. CBPHNs can utilize these study results to bolster those existing efforts. The CBPHNs can also use study findings to educate local leaders, leveraging other public health resources, such as environmental health staff and policy analysts, to advocate for changes in indoor air quality regulations. To address participants’ experiences with unequal access to resources, CBPHNs can engage various neighborhood resource teams around the city, which were created to coordinate, develop, and improve city services to neighborhoods in collaboration with residents and other partners. As public health employees, CBPHNs also have the role and responsibility of addressing the deleterious outcomes associated with historical redlining and other racialized injustices, as these nurses have key advocacy roles in policy development and enforcement.39,40 The role of the CBPHN is to partner with community residents in implementing long-standing public health programs and resources to advance health equity by eliminating structural and social systems that overexpose Black communities to unjust environmental health hazards.
CONCLUSION
Our findings highlight the association between perceived environmental injustices, self-reported stress, and health among Black residents, who increasingly are overburdened by racialized environmental exposures and concerned with structural barriers and environmental conditions that increase morbidity and mortality instead of optimizing community heart health and well-being. Local health department CBPHNs are responsible for addressing these environmental injustices and promoting health equity through authentic community partnerships.
Footnotes
ACKNOWLEDGMENTS
The authors sincerely thank the community members and research participants who made this study possible.
AUTHORS’ CONTRIBUTIONS
J.L. and L.D.O. led the study conception and design. Material preparation, data collection, and analysis were performed by J.L., F.K., H.O.W., and L.D.O. The first draft of the article was written by J.L., F.K., H.O.W., R.F., S.H., K.P., P.Y., and L.D.O. All authors read and approved the final article.
AUTHOR DISCLOSURE STATEMENT
Authors have no conflicts of interest to disclose.
FUNDING INFORMATION
This work was generously supported by a grant from the University of Wisconsin-Madison Institute of Diversity Science and the Louis J. and Phyllis Clark Jacobs Professorship in Mental Health.