Narration Transcript Final Project 8034
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Final Project: Narration Transcript
Dr. Leischner
PUBH 8034
4/15/2024
Environmental Health
: Local to Global (Slide:1)
On behalf of Group B team members, I hope that everyone is having a fantastic day. Group B Team of public health specialists are here today to address a public health emergency involving the emission of methylene chloride and mercury from a manufacturing industry.
Addressing a Public Health Emergency Involving the Emission of Two Chemicals: Methylene Chloride & Mercury
Group B Staff Members: Marites L. Calinawan: Facilitator, Human Exposure Information, Prevention Information. Kerrine Mclean- Wilkie: Monitoring, Evaluation. Parvaneh
Zare: Hazard Investigation, Social Change. Alexandra Teresa Hapenny: Innovative Solutions, Narration Transcript, Systems Thinking Tool. Rasheed Adeola Mumin: Title Slide and Objectives/Creative Aspects of Scenario, References and Citations.
Objectives of the Presentation:
(Slide 1)
Objectives of this Presentation: This presentation dives into the environmental health concern with clarity and profoundness. It talks about two hazardous chemicals: Mercury and Methylene Chloride. It outlines specific issues like health hazards and associated health risks. It highlights possible ways to prevent exposure of the chemical to the environment, it also dives into the innovative ways to collaborate with local agencies to help prevent negative outcomes from the exposure of these chemicals. You would be informed on the monitoring plans for community health status, as well as an evaluation framework highlighting outcomes and methodological strengths and limitations. The presentation concludes by placing the local issue within a broader societal context, advocating for positive change.
Diagnose and Investigate:
Hazards and Health Issues (Slide 1)
Mercury: mercury is a highly toxic heavy metal that poses significant environmental and health risks. One of the primary environmental health issues related to mercury is its widespread presence in the environment due to both natural processes and human activities. Mercury exists in various forms, including elemental (metallic) mercury, inorganic mercury, and organic mercury. Chemicals/Hazards Present: The main chemical of concern in mercury exposure is methylmercury, which is formed when mercury is released into the environment and undergoes methylation by microorganisms. Methylmercury bioaccumulates in aquatic food chains, leading to higher concentrations in fish and seafood. Health Issues Caused: Exposure to mercury, especially methylmercury, can have severe health effects on humans. It primarily targets the nervous system and can lead to neurological disorders, developmental delays in children exposed
prenatally, cognitive impairment, and other adverse health concerns. Fate/Transport: Mercury can cycle between air, water, and soil through various processes like volatilization, deposition, and methylation, and also bioaccumulation. Once released into the environment, mercury can travel long distances through the atmosphere and being deposited back onto land or water bodies.
Environmental & Biological Persistence: Mercury is a persistent environmental contaminant due to its ability to cycle between different environmental components. In aquatic environments, methylmercury can persist for a long time and stay in the food chain. In biological systems, once ingested or absorbed, mercury can accumulate in tissues and remain there for extended periods. Environmental Health issues to mercury is it’s like a cycle basically.
Diagnose and Investigate:
(Slide 2)
Methylene chloride, also known as dichloromethane, is a volatile organic compound commonly used as a solvent in various industrial processes such as paint stripping, pharmaceutical manufacturing, and metal cleaning. While it has several industrial applications,
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exposure to the methylene chloride can pose significant environmental and health issues. Chemicals/Hazards Present: Methylene chloride is a colorless, volatile liquid with a sweet odor. When it enters the environment through industrial discharges or improper disposal, it can contaminate air, water, and soil. Health Issues, the people can get exposed to the methylene chloride can lead various health issues, including respiratory irritation, headaches, dizziness, nausea, and in severe cases, damaging the nervous system, depression. And also who has the really high level of exposure they can get the lung damage, or liver damage or cancer. Fate and Transport: Methylene chloride released into the environment can undergo evaporation into the atmosphere due to the volatile nature. Once in the air, it can be transferred over long distances before eventually degrading through reactions with other chemicals or sunlight. Environmental & Biological Persistence: Methylene chloride has moderate persistence in the environment. In water bodies, it can accumulate in the sediments and persist for extended periods. In biological systems, methylene chloride can be metabolized into carbon dioxide and excreted from the body over time to its toxic and potentially widespread exposure. So proper handling and disposal practices are essentially reducing the risk and protecting both humans and the environment
.
Potential Risks of Human Exposure:
(
Slide 1)
The potential risk for human exposure for Methylene Chloride or Dichloromethane is it’s health effects on workers’ exposure to industrial manufacturers of paint removal and bathtub refinishing
with stripping agents, pharmaceutical manufacturing, metal cleaning, and degreasing as stated by
Occupational Safety and Hazard Information (OSHA), 2013).
OSHA (2013) added that long-
term exposure through inhalation and skin absorption may cause human cancers, such as
liver, lung, breast, and salivary glands (OSHA, 2013).
The known dose response for dichloromethane may cause antispasmodic and relaxant effects on rats’ digestive tract system precontracted with
carbachol or potassium chloride (Beyi et al., 2023). With this I was not able to look for any articles on human exposure, but this is the known dose response effect on rat’s digestive tract system.
Potential Risks of Human Exposure:
(
Slide 2)
For Mercury, potential risks for human exposure according to (Falta, 2022)
industrial factories dump mercury into a flowing body of water, leading to contaminated water
where fishermen catch fish for consumers.
A heavy metal that settles or is deposited with rain or snow when it vaporizes and moves into the atmosphere.
It becomes concentrated in the muscles of fish, which people eat.
It is found in large saltwater fish (tuna or swordfish) or freshwater fish (bass or pike). Infants in utero can be exposed to mercury consumed by the mother, causing mental retardation, cerebral palsy, deafness, and blindness. High-level exposure causes “Mad Hatter Syndrome” with signs and symptoms of excitability, delirium,
and hallucinations.
Known dose response: a risk factor for cardiovascular disease (i.e. ischemic heart disease) and stroke (Hu et al., 2021).
Informing the Community:
Strategies useful to community members to prevent adverse health outcomes: (Slide 1)
The next slides will discuss strategies useful to community members to prevent adverse health outcomes. For methylene chloride, OSHA training on methylene chloride hazard communication and personal protective equipment hazard standards as recommended by (OSHA, 2013).
Safe work practices include adequate ventilation, respiratory protection, protective clothing, and equipment (OSHA, 2013).
Use alternative or less hazardous chemicals or methods to eliminate methylene chloride also as recommended by (OSHA, 2013).
(Lynch et
al., 2023) recommended occupational risk assessments focusing on occupational chemical exposure as recommended by the United States EPA under the Toxic Substances Control Act or TSCA. This approach aids in preventing the mischaracterization of exposures and current industrial practices in identifying occupational exposures.
Informing the Community:
Strategies useful to community members to prevent adverse health outcomes: (Slide 2)
For Mercury, education information recommendations from the United States Environmental Protection Agency (EPA) and US Food and Drug Administration (USDA) on fish consumption for pregnant women or plan to become pregnant (Falta, 2022).
Public health advisories directed to recreational fishermen about the health risks associated with mercury-
contaminated fish (Falta, 2022).
Education on preventative measures acquired through long-term
inhalation exposure and skin absorption about the hazardous health effects of mercury, these were all cited from (Falta, 2022). The other strategy is genetic testing of people who had chronic exposure through intake of contaminated fish causes damage to the central nervous and cardiovascular systems and also (Crespo-Lopez et al., 2023) added that genetic testing can be done through the use of single base polymorphisms (SNPs) genes to check proteins responsible for the absorption, distribution, metabolism, excretion; and
interactions with molecular targets and adverse effects of mercury (Crespo-Lopez et al., 2023).
Innovative Solutions
:
Methylene Chloride (Slide 1)
Reduce, limit, or if possible, prohibit the production, and disbursement of methylene chloride in all public use. Reduce/ limit industrial and commercial use. Create strict safety standards in work environments workplace so the remaining uses of methylene chloride do not
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harm employees. Require distributors, suppliers, importers, and producers of methylene chloride to inform companies who come in contact with the chemical to maintain records of contact. To address this public health issue, it is important to control exposures in the workplace since that is who is most at risk for harmful effects from methylene chloride. Because of the severity of the issue on humans and the environment, this is a public health issue that needs to be addressed. Create strict safety standards in work environments so the remaining uses of methylene chloride do not harm employees. Create financial and tax incentives for companies to use alternate chemicals. Create opportunities for the public to educate themselves about any legislative changes concerning methylene chloride, including email lists, 1:1 scheduled meetings or organizational meetings, and recording video conferences regarding the risk and new regulations.
The National Institute for Occupational Safety and Health suggests (Methylene Chloride | NIOSH | CDC
, 2020) that employers use the Hierarchy of Controls to eliminate or change the use of toxic chemicals, substitute toxic chemicals to a safer alternative, or alter equipment design, alter administrative control and personal protective equipment to minimize exposure to toxins. Implementing new training requirements will also be effective concerning methylene chloride handling.
Innovative Solutions
;
Mobilization Methods
: Methylene Chloride (Slide 2)
Connecting Community Members and Organizations
: Communicate with community members and organizations to voice concerns, public comments, and input. The Environmental Protection Agency (US EPA, 2016) allowed public comments to be posted about methylene chloride regulation change 60 days after publicizing. Our team will implement open forums online so the public can ask questions and comment on Methylene Chloride initiatives. Create financial and tax incentives for companies to use alternate chemicals. The Environmental
Protection Agency (US EPA, 2016) allows individuals in the public to seek information on their Risk Management Page, and to schedule 1:1 meetings to gain more information on the chemical and efforts towards risk management. They also provided consultation webinars targeting environmental justice communities and findings from the risk elevations. Our team will create opportunities for the public to educate themselves about any legislative changes concerning methylene chloride, including email lists, 1:1 scheduled meetings or organizational meetings, and recording video conferences regarding the risk and new regulations.
Innovative Solutions
:
Mercury (Slide 3)
Mercury-containing batteries started getting phased out during the Battery Act which applied to waste handlers, producers, importers, and retailers. Metallic mercury became illegal to
distribute, sell, and transport, by federal agencies. Exporting became illegal in 2013 according to the EPA (2015). The Clean Air Act listed mercury as one of the air toxics to be regulated and created emission standards and required permits to adhere to. The Clean Water Act created standards for water sources and set pollution regulations to protect the health of humans and wildlife. It also identified mercury sources and determined the limitations that are necessary to achieve the quality needed. The Safe Drinking Water Act studied the erosion of natural mercury deposits, unnatural discharges, and runoffs to create safe drinking water regulations by state. The
Resource Conservation and Recovery Act, according to the EPA (2015) sets mercury emission limits regarding hazardous waste transportation, storage, and removal. Engagement of stakeholders and public health officials to discuss and implement more public health initiatives and research to help limit and eventually eliminate the risk of mercury exposure since it is a continuous public health issue that has a detrimental effect on those exposed and needs to be
addressed. Provide more public education about the risks of mercury exposure to those at highest
risk and how to handle, avoid, and dispose of mercury-containing products.
Innovative Solutions
;
Mobilization Methods:
Mercury (Slide 4)
Community Members
and Organizations: The EPA (2015) allows for any U.S. resident to petition to be exempt from metallic mercury exporting. They also published a 21-page
text that explains the Battery Act in detail. Because the Resource Conservation and Recovery Act
Mercury exempts household hazardous material from the act, it would be useful to disburse more
educational tools on how to store and dispose of mercury-containing materials safely in the home
environment via online videos and pamphlets. EPA (2015) and United States publicize information concerning waters contaminated with mercury and the risks of mercury exposure. They also warn the public about eating fish contaminated with elevated amounts of methylmercury. Through the Emergency Planning and Community Right-to-Know Act (EPCRA)
federal and industrial companies are required to report mercury and mercury compound emissions through the Toxic Release Inventory Program. Community efforts will include enforcing, educating, and promoting The Clean Water Act, The Safe Drinking Water Act, and The Clean Air Act. Promoting families to follow state and national standards concerning fish consumption and to avoid purchasing products that contain mercury such as analog thermometers. Public education that promotes practicing proper disposal, handling, or recycling of products and older medicines that contain mercury as stated by the SCDHEC (
Health Risks of Mercury | SCDHEC
, n.d.). Sharing our efforts on a global scale to help promote similar procedures in other countries at high risk will help mitigate the issue around the world. Monitor the Health Status:
Slide 1
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How healthcare agencies plans on monitoring and engaging in surveillance for this issue: Public health agencies are able to use several tools and services to monitor and engage the public on the healthcare concerns regarding mercury and methylene chloride. Healthcare key performance indicators (KPIs) are measurable metrics that help to track progress and also identifies room for improvement (National Library of Medicine, 2017). This method is driven through data-driven analysis and strategies to improve patients and communities (National Library of Medicine, 2017). Using mortality: The rate of death is on of the helpful indictors that can track mortality rates once the implementation of this healthcare concern is addressed. For example in the year of 2019 there were a high mortality rate of industrial workers due to exposure to methylene chloride and mercury, after human resources implemented personal protective equipment such as gloves, masks, googles, booties, and overalls. Mortality rates or visits to the emergency rooms were reduced dramatically (National Library of Medicine, 2017). Monitor if sales for indoor cooking stoves and electric stoves have increased in regions where healthcare officials have educated and advertised alternative ways to reduce contaminated gas release. Monitor regional and global sales of personal protection gears such as googles, masks, gloves, and disposable overalls by the industrial market. Monitor companies that sell products that contain mercury and methylene chloride are placing labels on their products to inform the public about hazardous ingredients that require individuals to properly ventilate work area while using product (National Library of Medicine, 2017). For example, after reaching an agreement with manufacturers, local and global products would display hazardous precautions labels on products. Healthcare officials can also partner with local and global hospitals, clinics, and wellness centers to verify if there has been a reduction or increase in patients since the campaign and awareness of the harmful compounds (National Library of Medicine, 2017).
Monitor the Health Status:
Slide 2
How communities should expect to address the healthcare concern of Mercury & Methylene chloride: Communities expect to address the healthcare concern of Mercury & Methylene chloride. Exposure to Mercury and Methylene Chloride, both odorless compound affects employees and communities on a local level where people are exposed to high-levels of this toxic substance through the air, water, and soil. Many individuals are exposed to mercury through high consumption of fish and shellfish that are contaminated with mercury and industrial
workers that inhale mercury through fuels or raw materials and this is through the (World Health Organization, 2017). However, exposure to Mercury has its toxic effects. On the individual’s nervous system, digestive, immune system, lungs, kidneys, skin, and eyes (World Health Organization, 2017).
Even small amounts of mercury can threaten the development of a child in utero (World Health Organization, 2017).
Other human activities locally such as residential cooking indoor/outdoor using coal-fired power stations, it releases gas in the air causing exposure to the individuals. Waste incinerators from mining for mercury and other metals also result in toxic release into the atmosphere affecting the individuals that are exposed (World Health Organization, 2017). Local effects to exposure of both compounds, Harmful exposure to gases affects industrial workers, families, pregnant women, and children that are exposed through consumption, air, water, and soil contamination. The World Health Organization (2017) also says that industrial workers are exposed, they in turn expose their families creating harmful effects on the nervous system, digestive system, immune systems, kidneys, and gastrointestinal tract (World Health Organization, 2017). Local communities and healthcare facilities are also exposed individuals that will be experiencing possible kidney failure, mental disturbances,
muscle weaknesses, memory loss, skin rashes and in gastrointestinal problems (World Health Organization, 2017). Global impacts of Mercury and Methylene chloride are certainly different, mercury has more global impact because of the consumption or the use of mercury through indigenous communities (World Health Organization, 2017). Global mercury can create harm to: Food provision for people that consume high-amounts of fish such as Canada and Alaska, Harm wildlife if other species are consumed more than others. Create an unbalance in the ecosystem, since fish and other seafood is usually the main protein supplement for many. Disrupting the natural flow of how many developing countries make a living or provide for themselves and families by cooking outdoors (World Health Organization, 2017). More cases of underdeveloped children impacting the healthcare system with cardiovascular issues (World Health Organization,
2017). Communities should address these topics by providing educational materials and guidelines to industrial workers and local communities at the markets where seafoods are sold. Construction sites should have local posters boarders providing side effects of mercury and methylene chloride so that workers can identify if they start to see these symptoms (World Health Organization, 2017). Community health fairs are perfect opportunities to take surveys and
provide information to nursing mothers, seniors, industrial workers, and other individuals about the side effects of these two compounds (World Health Organization, 2017). If individuals are made aware of these concerns, they will remain proactive in keeping safe. How Solutions Will Be Evaluated:
Slide 1
How does healthcare agencies plan on addressing and mitigating the concerns for the community:
So, first addressing local & global companies to implement educational materials such as poster boarders, local health fares, mobile health vans, addressing the public
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about the concern for these compounds that is a health concern (American Public Health Association , 2024). Tracking signs and symptoms of outbreaks will help local healthcare officials contain the spread and impacting other communities creating an epidemic (American Public Health Association, 2024).
Tracking outbreaks through signs and symptoms will create safety standards such as protective personal equipment such as gloves, masks, overalls, and booties as apart of mandatory protocol equipment usage while working with compounds such as methylene chloride (American Public Health Association, 2024).
Aide food industry companies to use cautionary instructional labels on products so that consumers, while using at home that proper ventilation is required. Packing companies can also educate buyers that fish and shellfish products may have exposure to methylmercury which is a health concern (American Public Health Association, 2024). Partnering with human resource departments at industrial companies to ensure workers wear protective gears while handling chemicals that contain or mercury and methylene chloride (American Public Health Association, 2024). For example, allowing human resources to enforce mandatory protective gears that employees are expected to wear when handling any products containing the compounds in question.
Finding alternative method of solution such as instead of telling rural women to stop cooking outside with coals and other materials that pollute the atmosphere with gases that is bad for inhalation. Healthcare officials for
that county can provide at a reduce cost gas stoves to be used indoors along with electric stove tops that provide a safer means for individuals to cook meals for their families. Encouraging families to create compost with household garbage instead of burning them (American Public Health Association, 2024).
How Solutions Will Be Evaluated:
(Slide 2)
Evaluation Design Strength and Limitations: Key performance indicators were used to manage and monitor communities, hospitals, clinics, industrial workplaces that were heavily influenced by the toxic components of mercury, and methylene chloride (National Library of Medicine, 2023). These outcome evaluations can vary from short term to long term evaluation, all depend on participation from participants and the desired outcome healthcare providers expect to establish in the community such as changes in health conditions, quality of life, and behaviors (Rural Health Information Hub, 2024). Rural health information hub explains that every program is unique to the desired goal or outcome: Program goals, Evaluation research questions, Purpose of the evaluation, and Available resources. As it pertains to educating, providing resources, mitigating healthy practices, making healthy choices, and conforming to healthier way of doing things. They are experimental designs that are used such as case study approaches that uses control groups to verify if these practices are improving (Rural Health Information Hub, 2024). For example if a high number of pregnant women in a community that largely consumes seafood containing high amounts of mercury were asked to changed their diet from seafood to soy products, beans, and grains that contained protein and other substances needed for a healthy pregnancy using a control group, there would be a difference in outcomes that would alter the desired outcome for pregnant women potentially being affected by mercury poisoning from seafood contamination (Rural Health Information Hub, 2024). Evaluation Framework that can be used in approach to reduce methylene chloride and mercury poisoning. These are process evaluations this systematic approach focuses on collecting data from the industrial companies, communities and families to gather the initial answers to the increase in health concerns of the compounds in question (Rural Health Information Hub, 2024). Outcome evaluation: This examines how well the initial outcome will be achieved, this is to bring
recommendation to future program improvements (Rural Health Information Hub, 2024). Impact
evaluation: This evaluates how well the approach was taken, was from the beginning to measure changes that resulted from those outcomes (Rural Health Information Hub, 2024). Performance Monitoring: This is an ongoing evaluation using the baseline assessment for continuous improvement and monitoring of implementation progress to better align future goals, objectives and goals (Rural Health Information Hub, 2024). Cost-benefit Evaluation: Reflects on the cost-
effectiveness of the program by reviewing the relationship between project costs and outcome. Collected data is also used to determine whether the investment is worthwhile (Rural Health Information Hub, 2024)
How Solutions Will Be Evaluated: Strengths and Limitations
(Slide 3)
Strengths and Limitations: Limitations to this approach can be costly; doing advertisements, poster boards, hiring healthcare advocates to go out into the communities with resources to educate and help the people. Full corporation from individuals to participate in the program. For example, human resources require that gloves and mask be always worn while handling products that contain methylene chloride. This requires the full corporation to see dramatic results. Culture plays a strong limitation for healthcare providers trying to educate participants in rural areas about practices such as using coal fire indoors for cooking or using indoor paint stripping components without proper ventilation. One of strengths in using performance monitoring and evaluation is health providers presence in the communities and workplace that marks a positive relationship and influences positive outcomes (Rural Health Information Hub, 2024). A Broader Context: Positive Social Change (Slide 1)
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Positive social changes can be increased by increasing awareness and education about all the chemicals, like mercury and methylene chloride, raising the awareness about the sources of the exposure and potential health effects, individuals can also change, make a good decision actually for diet and changing lifestyle. Education programs can also help communities, especially the people who have high-risk like pregnant women and children, and the people who have a job that exposes to those chemicals. Policy Change: Knowledge about the impact of chemicals can drive policy changes at local, national, and international levels. Advancements in the Health Care: Improved monitoring techniques for measuring mercury levels or methylene chloride levels in the blood, hair, or urine for early exposures. Healthcare providers can play a crucial role in educating patients about chemicals exposure risks and make the recommendation. Environmental Conservation Efforts: Understanding the pathways of the chemicals in the environment can inform conservation efforts aimed at reducing chemical levels in water bodies and aquatic ecosystems. Sustainable practices can help mitigate the bioaccumulation of the mercury in fish. Community Empowerment: Communities affected by high level of exposure, such as coastal populations or people working close with the methylene chloride, they all can get
benefit from targeted interventions that promote safe dietary choices or even lifestyle or even using regular monitoring of the exposure levels. And at the end research, continued research about the health effects of exposure to all these chemicals and having more treatment strategies and the public health interventions and also collaborating with the scientists, policymakers, healthcare providers, and communities can lead to comprehensive approaches to addressing chemical exposure.
Systems Thinking Tools:
Local and Global Impacts (Slide 1)
The EPA (2015) suggests that global mercury emissions from anthropogenic sources add up to 2220 metric tons annually. In the United States, due to Mercury pollution, 44 states implemented fish consumption advisories, and the number of river miles with advisories increased by 60% in 2003 according to NYSERDA (
Mercury, Human Health, and the Environment
, n.d.). 25% of the U.S. rivers and about 33% of lakes have advisories not to consume fish and approximately 60,000 children in the U.S. are at risk for nervous system damage due to methylmercury exposure from their mother’s womb. The CDC acknowledged 8%
of women of childbearing age had unsafe mercury levels in their blood in 2003 as stated by NYSERDA (
Mercury, Human Health, and the Environment
, n.d.). The rising demand and expanding use of Methylene Chloride exists in Asia-Pacific, South Korea, China, India, and Japan, mostly due to the building, construction, and automotive market growth according to Custom Market Insights
(
Global Methylene Chloride Market Size Reach $39.9 Bn 2032
, n.d.). North America held the second largest share and the United States and Canada are major contributors. Methylene chloride can damage the skin, heart, liver, and eyes. It can cause numbness, nausea, loss of consciousness, dizziness, and in some cases, cancer, or death. Workers
are at risk of exposure and the severity depends on the type of work (as methylene chloride is used in many industries for paint removal, cleaning, and manufacturing), the duration, and the dose. Workers can be exposed to methylene chloride through paint-stripping products, glazing fumes, metal cleaning and degreasing, and workers in pharmaceutical production according to the CDC (
Methylene Chloride | NIOSH | CDC
, 2020). Systems Thinking Tools: (Slide 2)
To address public health issues, it is important to control exposure in the workplace since that
is who is most at risk for harmful effects from methylene chloride. Because of the severity of the
issue on humans and the environment, this is a public health issue that needs to be addressed. Concerning mercury, more public education about the risks of mercury exposure to those at highest risk and how to handle, avoid, and dispose of mercury-containing products needs to become more accessible.
Surveys will track outbreaks at every stage and accountability partnerships will form between human resource departments. Warning and instructional labels on
products to help educate the public. Using posters, local health fares, mobile health vans, increasing public education, and promoting in place and new legislative rules and guidelines for safe mercury and methylene chloride handling and avoidance. Tools will include Process Evaluation: according to Rural Health Information Hub (2024), this will collect data from industrial companies and the community to address health implications concerning mercury and methylene chloride. Outcome Evaluation will examine effectiveness which will determine any changes to an intervention in the future and impact evaluation will be used to measure the various stages of an approach. Cost- benefit evaluation analysis the correlation between cost and results and performance monitoring will be an ongoing assessment used for uninterrupted enhancements, refinements and monitoring of an intervention to ensure outcomes align with the goals and objectives according to Rural Health Information Hub (2024).
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