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Advances in Nursing Science

Vol. 32, No. 2, pp. 107–117


Copyright  c 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

The TERRA Framework


Conceptualizing Rural Environmental
Health Inequities Through an
Environmental Justice Lens
Patricia Butterfield, PhD, RN, FAAN; Julie Postma, PhD, RN, and the
ERRNIE research team

The deleterious consequences of environmentally associated diseases are expressed differen-


tially by income, race, and geography. Scientists are just beginning to understand the conse-
quences of environmental exposures under conditions of poverty, marginalization, and ge-
ographic isolation. In this context, we developed the TERRA (translational environmental
research in rural areas) framework to explicate environmental health risks experienced by
the rural poor. Central to the TERRA framework is the premise that risks exist within physical-
spatial, economic-resources, and cultural-ideologic contexts. In the face of scientific and polit-
ical uncertainty, a precautionary risk reduction approach has the greatest potential to protect
health. Conceptual and technical advances will both be needed to achieve environmental jus-
tice. Key words: environmental health, intervention studies, public health, rural health,
social justice

C ONCEPTUAL frameworks addressing en-


vironmental health (EH) inequities in ru-
ral communities are few and far between.
To address this deficit, to capture nursing’s
multifaceted perspective, and to provide a
conceptual foundation for our own studies
As a result, nurses examining the social de- with rural low-income families, we developed
terminants of EH in underserved and rural the TERRA (translational environmental re-
communities have had few choices to con- search in rural areas) framework. With a dual
ceptually ground their work. Because of the emphasis on risk (from multiple agents) and
challenges in finding conceptual frameworks risk perception, the framework is intended
that reflect a nursing lens, some studies have to strengthen nursing’s rapidly evolving body
been conducted atheoretically; others have of science addressing EH and environmen-
adapted frameworks from other disciplines. tal justice. Sequentially, this article includes
a summary of (1) advances in exposure anal-
ysis, (2) issues shaping rural EH inequities,
Author Affiliations: Washington State University
(3) TERRA’s development, (4) concepts and
College of Nursing, Spokane, Washington practice examples from the TERRA frame-
(Drs Butterfield and Postma). Dr Postma completed work, (5) similarities and differences among
this work during her Postdoctoral Fellowship at the
University of Washington School of Nursing. The
other social-cognitive EH frameworks, and
ERRNIE team includes: W. G. Hill, P. W. Butterfield, (6) the importance of conceptually driven EH
L. Larsson, K. Harnish, G. Barnes, M. Schure, inquiry.
T. Maryon, B. Tinker, and participating public health
nurses. MEASURES BEFORE MEANING: A
This work is supported by NIH NINR R01NR009239, Re- SUPERFICIAL HISTORY OF ANALYTIC EH
ducing Environmental Risk to Rural Low-income Fami-
lies, and NIH NINR, T32NR07039, The Women’s Health
Nursing Research Training Grant. The past 10 years has been a remark-
able time for the conceptualization and
Corresponding Author: Patricia Butterfield, PhD, RN,
FAAN, Washington State University College of Nursing, measurement of EH exposures. The Insti-
PO Box 1495, Spokane, WA 99210 (pbutter@wsu.edu). tute of Medicine reports addressing medical
107
108 ADVANCES IN NURSING SCIENCE/APRIL–JUNE 2009

curricula, nursing competencies, environ- ventions compatible with the realities of rural
mental justice, and EH indicators included public health systems.
specific recommendations addressing curric- In many rural areas, attitudes toward EH is-
ular insertion points.1–4 Advances in analytic sues are strongly influenced by economic fac-
techniques gave scientists the ability to ob- tors (eg, finding and keeping a job) and a per-
tain reliable low-cost estimates of exposure vasive distrust of government oversight. As
to prevalent agents such as pesticides and rural communities transition from old (ie, ex-
metals.5 Armed with a new generation of ex- tractive industries) to new (ie, service indus-
tremely sensitive tests that were able to cal- tries, construction) economic realities, they
culate contaminants at the parts per billion often experience wide variations in employ-
level, scientists were often challenged in in- ment, a phenomenon that Bashir refers to as a
terpreting analytic test results in meaningful “feast or famine economic cycle”10(p738) Low-
ways for clinicians, policy makers, and grass- income families are frequently caught up in
roots activists. local economic downturns, resulting in the
loss of insurance benefits, extended periods
of un- or underemployment, the economic ne-
WHY RURAL MATTERS cessity of multiple part-time jobs, or both. The
proximity of residential to agricultural prop-
The vernacular of EH science comes from erty, coupled with lax zoning, lower property
toxicology and epidemiology and is couched values, and less sophisticated local resistance
in the language of scientific uncertainties (eg, has meant that poorer residents often live ad-
confidence levels, P values). While EH scien- jacent to a variety of point source polluters,
tists understand the merits of this perspec- ranging from confined animal feeding opera-
tive, citizens do not. Citizens want to know tions to underregulated small businesses (eg,
how to fix problems in their homes and get automotive shops), illicit methamphetamine
help from local officials. Those living in ru- laboratories, or both.11–13
ral areas face additional challenges in obtain-
ing EH risk reduction advice. Away from city-
level municipal services, such families may TERRA: CONCEPTUAL INSIGHTS
rely on equally uninformed neighbors for ad- FROM EMPIRICAL ROOTS
vice about septic systems, drinking water,
well maintenance, and household hazards.6,7 Our research focuses on testing the impact
Rural health services are frequently under- of environmental risk reduction (ERR) inter-
funded, understaffed, and/or undermined by ventions on health indicators in rural Mon-
local officials, with some areas receiving al- tana and Washington families. Similar to the
most no services.8,9 As a consequence of per- rural southwest,14 the performance sites are
petual underfunding, public health officials located in communities strongly influenced
may become aware of EH problems only af- by gentrification, with housing costs driv-
ter the “cow is out of the barn,” forced at ing the relocation of both wealthy and low-
that point to focus on secondary rather than income families. In both communities, low-
primary prevention efforts. Many small towns income families who move “out of town” in
lack safety net programs intended to mitigate search of less expensive housing often end up
problems associated with substandard hous- with problems (eg, septic failures) they nei-
ing, agricultural runoff, and improper waste ther understand nor have the resources to fix.
disposal. This dynamic can leave citizens with Like many places in the intermountain West,
the impression that they need to solve prob- we work in communities that are predomi-
lems on their own; an impression that may or nately white but rigidly stratified by income
may not be well founded. Hence, the need and class distinctions. Hispanic and Native
to develop and test the impact of EH inter- American persons in our communities often
TERRA: A Conceptual Framework 109

express feelings of linguistic isolation, cultural EH threats rather than adopting a piecemeal
isolation, or both. “Main street” represents a single-agent approach to EH.15 This holis-
culture in transition, with feed stores and au- tic approach is echoed in Native and Mexi-
tomotive repair shops located near high-end can American perspectives on environmental
boutiques. In our communities, “trust fun- decision making and management.16,17 Subse-
ders”shop at the organic grocery store; young quent efforts yielded a framework that cap-
“minimum wage” families shop at Wal-Mart. tured the dilemmas as well as the opportuni-
Two small qualitative studies informed pre- ties for families to act in response to multiple
liminary development of the TERRA frame- risks.
work; an initial study with low-income The scope of the TERRA framework is nar-
rural mothers and a second study of local lead- row enough to provide guidance for our in-
ers’ perceptions of EH risks.6,7 These studies tervention research (Environmental Risk Re-
helped structure rural citizens’ involvement duction Through Nursing Intervention and
in the formulation of the framework. Findings Education [ERRNIE] study6,7,18 ), yet broad
from this work provided evidence of the di- enough for us to see the influence of micro-
alectic tension between mothers’ feelings of and macroeconomic factors on health behav-
being “trapped” in poverty and leaders’ be- ior. Although relatively young in the theory
liefs that Westerners wanted to live as reg- development process, we have found that the
ulatory free as possible. This evidence com- TERRA framework is able to accommodate a
pelled us to build a framework that explicated multifaceted approach to inquiry, thus allow-
what EH actions were rationally at the dis- ing us to concurrently examine children’s EH
posal of families and what actions were not exposures and parents’ capacity to prevent or
accessible to families because of poverty, pub- respond to EH risks.
lic health service gaps, and/or prevailing po-
litical/economic ideologies.
Our work was further informed by the SUMMARY OF FRAMEWORK
World Health Organization’s ME-ME (multiple
exposures—multiple effects) model, which Information addressing the TERRA frame-
emphasized the need to look holistically at work is provided in Figure 1 and Table 1.

Figure 1. TERRA framework: Key concepts and examples. Abbreviations: EH indicates environmental health;
ERR, environmental risk reduction; and TERRA, translational environmental research in rural areas.
110 ADVANCES IN NURSING SCIENCE/APRIL–JUNE 2009

Table 1. TERRA framework: Concept descriptions and examples

Concept description Example

Macrodeterminants: Ecological- or societal-level antecedents of EH


Physical-spatial: Variations in geographic and Contamination of drinking water from
spatial characteristics of a region application of fungicide on fields; geographic
isolation
Economic-resources: Variations in a region’s Increased housing costs associated with
economic vitality gentrification
Cultural-ideologic: Variations in citizen’s belief Prevailing norms addressing self-reliance, sense
systems of space
Family-level determinants and outcomes
EH inequities: Differential distribution of Choices families have to make in relation to
resources available at the family level paying rent or fixing leaky roof
EH risks: Potential harm from biologic, Multiple agents in home setting: water
chemical, physical, or social agents contaminants, lead, airborne radon,
environmental tobacco smoke, carbon
monoxide, mold/moisture, methylmercury
EH mental models: Social-cognitive Perceptions that one’s children are or are not at
constructions of risk risk for health problems from airborne radon
ERR interventions: Education, guidance, and No-cost/low-cost options to reduce EH risks;
mitigation addressing EH risks interactive educational tools
Outcomes: change in risk, risk perceptions, or
both
Proximal: Changes in social-cognitive Families’ knowledge, self-efficacy
constructions of risk
Distal: Changes in ERR actions; reductions in Behaviors adopted to reduce children’s
exposures, disease exposure

Abbreviations: EH, environmental health; ERR, environmental risk reduction; TERRA, translational environmental re-
search in rural areas.

Figure 1 addresses key concepts and re- playing field about health protection options.
lationships; Table 1 includes a description Making them explicit allows more accurate
of concepts and respective examples. Con- insights into risk reduction actions by fam-
cepts in the framework include the follow- ilies that may seem short sighted from an
ing: (1) Macrodeterminants of EH, are mul- outsider’s perspective. While macrodetermi-
tifaceted and include physical-spatial (eg, nants are just that—macro- and societal-level
topography, climate, proximity to services), influences—EH inequities reflect resource
economic-resources (eg, power base of local availability at a family level and provide a
businesses, social safety net), and cultural- more immediate context for ERR interven-
ideologic elements (eg, property rights and tions. Understanding EH inequities can help
land use norms). (2) EH inequities, re- guide the delivery of public health interven-
fer to the differential distribution of re- tions for families that do not own a reliable
sources available to reduce exposure to vehicle or live in a weather-proof home. (3)
environmental risks. Best viewed as gaps EH risks, refer to the potential for expo-
between the rich and poor about income, sure to biologic, chemical, physical, and social
housing, neighborhood entrée, and job op- agents with deleterious health consequences.
portunities, EH inequities reflect the unequal (4) EH mental models, refer to beliefs about
TERRA: A Conceptual Framework 111

risks. People decide to act (or not) on the about self-reliance and a sense of place.6,16,20
basis of a social-cognitive construction of a This conceptualization, which presupposes
risk; this “mental model” may or may not re- that macrodeterminants play a key role in the
flect current scientific views about EH.19 (5) generation of EH risks, is similar to related
ERR interventions, are delivered by health conceptualizations addressing environmen-
providers, can either directly mitigate EH risks tal justice, the built environment, and EH
or indirectly alter the mental models path- indicators.
way, such that citizens act to change their
risk. (6) Proximal outcomes, such as knowl-
edge, risk interpretation, and/or self-efficacy,
are the tools that families need to have both Inequities
the information and confidence to act. These In an examination of rural hospitals in the
outcomes may or may not result in a change in United States, DeVries concluded that “when
risk reduction behavior. (7) Distal outcomes, you’ve seen one, that’s all you’ve seen.”21(p38)
refer to families’ ERR actions, reductions in Such a conclusion is equally apropos in
exposure, and decreases in disease incidence, trying to understand the subtle and multi-
severity, or both. plicative effects of inequities faced by rural
families. In addition to well-documented dif-
ferences in income between urban and rural
EXPLICATION OF KEY CONCEPTS citizens, race/ethnicity, economic vitality, and
health access issues also impact families.22,23
Macrodeterminants Both our research sites have had a recent in-
The natural and anthropogenic world flux of affluent retirees and telecommuters
sets the stage for EH risks and citizens’ into the area. Low-income families in these
perceptions of those risks. The TERRA communities now face a de facto competi-
framework focuses on physical-spatial, tion for resources with families who do not
economic-resources, and cultural-ideologic need a local paycheck to make ends meet.
determinants, not because they encom- Rather than urban gentrification patterns that
pass all EH risks (they do not), but rather typically displace low-income citizens, Yagley
because they influence the options that and colleagues24 noted that the rural poor are
rural citizens have to respond to EH risks. more likely to be “locked out” by gentrifica-
For example, citizens living by agricultural tion, discovering one day that they no longer
fields are impacted by the physical-spatial have access to riverfronts or open space. Only
characteristics of the site (eg, pesticide 50% of Montana residents’ income comes
dispersion patterns) as well as the area’s from within the state, so that economically
economic vitality (eg, housing affordability). and professionally connected citizens live in a
Ideologic themes in public hearings often different world than those relying on the local
reflect a variety of themes, ranging from the economy.25 In our studies, EH inequities often
attribution of blame to viewing EH hazards “look like” a family living in a trailer with no
as a quid pro quo for local high-paying jobs. insulation, a leaky roof, and well water they
It is common for us to hear workers attribute do not trust. In this context, overt and imme-
local job losses to “government interference” diate demands for resources (eg, rent) often
or “environmentalists” rather than market take precedence over desired but less press-
forces or business decisions. Ideologic de- ing needs (eg, home repairs). Finally, rural EH
terminants vary by community and agent inequities are only one facet of a broader con-
of concern; however, like Native American stellation of disparities that impact families of
and southwestern Hispanic communities, color, those on tribal nations, and those iso-
the communities in which we work both lated by language, culture, or with beliefs out-
influence and are influenced by strong beliefs side the prevailing norm.22,26
112 ADVANCES IN NURSING SCIENCE/APRIL–JUNE 2009

EH risks EH mental models


Environmental health risks refer to the po- Risks are perceived dynamically, with
tential of an agent to induce a health problem. thoughts and feelings contributing to citizens’
Our study addresses household risks such as conclusions about EH risks and the impact
radon, carbon monoxide, mold/moisture, wa- they can have on them. Cognitive psychol-
ter contaminants, methylmercury, lead, and ogy and neuroscience provides evidence that
secondhand smoke. EH risks vary remark- people develop personalized risk understand-
ably across hydrogeographic regions and in ings through 2 interacting systems; a cogni-
relation to unique local features (eg, agri- tive analytic system and an intuitive expe-
cultural crops, geology).Unfortunately the ag- riential system.31 Applied studies of human
gregation of EH data at state and regional behavior provide evidence that people are
levels often homogenizes such differences, most concerned about tangible EH risks in
further enhancing the invisibility of local yet their community.19 Information from one’s
severe problems.22 This problem is exacer- experience is integrated into personal un-
bated by our limited understanding of genetic derstandings that fall on a continuum from
polymorphisms and variations in individuals’ being absent to well developed. These be-
susceptibility to exposures. Both issues de- liefs, which may differ widely from estab-
crease the signal-to-noise ratio in EH, making lished knowledge, form the basis for decisions
it even more difficult to link exposures with and actions. For example, participants in our
disease consequences. study were asked to rate their level of con-
Rather than focusing on a single agent- cern about a number of local issues. Not sur-
outcome relationship, many EH scientists, in- prisingly, tangible risks were ranked higher
cluding ourselves, are quantifying risks to than intangible risks, with higher levels of
multiple agents within a specific setting, such concern noted for mold and Hantavirus, than
as a home or school. From running multiple for airborne radon, despite widely dissemi-
tests in a home, we have noted patterns in nated information that local radon levels were
our laboratory test results as they come in; frequently found to be above the EPA action
the presence of one positive test was a strong level.
predictor of subsequent positives.27 It makes
sense that a home that is substandard in one
way (eg, elevated carbon monoxide levels) is ERR interventions
likely to be substandard in multiple ways (eg, Environmental risk reduction interventions
leaky toilet seals and mold growth). Such a are based on the premise that mental models
“confluence of environmental risks” charac- can be reinformed through the provision of
terizes the pervasive influence that poverty salient health information. Dixon and Dixon32
imposes on rural children. An “examination noted the limitations of EH education materi-
of the health consequences of singular risks als and proposed a broader approach to the
may underestimate the true environmental epistemology of risk reduction information.
risk profile of low-income children.”28(p1942) The TERRA framework is consistent with this
This conceptualization of risk is consistent approach and based on the belief that the pro-
with a social ecological perspective, which vision of agent-specific information is insuffi-
challenges the merit of theories that quantify cient to improve public health. Rather, health
causation in “a thicket of decontextualized is considered as a whole within the context
factors.”29(p148) The work of May et al30 ex- of multiple EH risks. For example, actions to
emplified this broader perspective. Working mitigate lead exposure, such as hand wash-
with a rural Texas colonia, she notes that EH ing and damp-mopping, will reduce risks from
information should be “laced with local mean- other agents as well. It is not uncommon in
ings and is produced from, rooted in, and con- our study to see well water results that reflect
nected to the local context.”30(p1573) a pattern of potential risks, even though each
TERRA: A Conceptual Framework 113

individual agent (eg, arsenic, nitrates, lead) is tion produced by all these agencies.”35(p121)
slightly below the threshold value. In such sit- While people may receive information about
uations, the intervention nurse discusses the various EH agents, safety judgments are typi-
ambiguities of well testing and may use the cally based on information integration. Our in-
test results to explain that, taken as a whole, tervention book incorporates photos of each
there may be additive rather than single risks intervention family’s children in the book it-
to children. self and is intentionally jargon free. The book
Consistent with the mental models per- is highly interactive and uses cutouts that
spective, TERRA is based on an informed allow a participant to open a window, see
decision-making approach that casts persons his or her test results, and compare his or
as active problem solvers. Motivational inter- her results with threshold values. There are
viewing strategies are used by the nurses to spaces to fill in contact information for local
elicit individuals’ risk beliefs and frame the in- service providers (eg, household hazardous
tervention using participants’ own arguments waste collection, county extension agent),
for change. This approach enables ERR rec- specific questions for health department per-
ommendations to be “compatible with re- sonnel, and personalized action plans. ERR
gional and political identity” versus those recommendations are low cost and practical
framed in outsiders’ language.6(p109) In keep- for resource-poor families. For example, run-
ing with the clinical principles upon which ning the tap for 5 minutes can help clear
motivational interviewing is based, partici- old pipes of standing water that may contain
pants’ ambivalence is accepted, argumenta- heavy metals. Setting up rain gutters to divert
tion is avoided, and resistance is explored.33 water away from the home can help prevent
Action items, such as ways to decrease chil- expensive home repairs later.
dren’s exposure to secondhand smoke, are ne-
gotiated between participants and the inter-
vention nurse. Outcomes
Our goal is to facilitate an iterative pro- Improvements in health are based on a se-
cess that promotes co-understanding about ries of complex and time-dependent events.
EH issues and concerns between researchers, People must see an issue as salient if they are
nurses, and communities in which we work. to use information about that issue.36 For ex-
This process is akin to the social capital ample, changes in asthma severity may (or
conceptualization of rural nursing proposed may not) be based on antecedent changes
by Lauder and colleagues,34 whereby rural in parental beliefs, behavior, and levels of in-
nurses are both integral members of rural home allergens. Some of the “healthy homes”
healthcare systems and rural communities. studies exemplify this approach and judi-
ciously select outcomes that capture changes
in health status (eg, number of days of β 2 -
Timing and elements of ERR agonist medication use) as well as the con-
interventions sequences of those changes (eg, number
Lindell and Perry noted that risk reduc- of workdays parent missed within the past
tion information is frequently provided in month).37 Commensurate with a process-
a piecemeal manner. They maintain that in oriented approach, the TERRA framework
many health departments different issues (eg, differentiates between proximal and distal
agents) fall under the jurisdiction of different outcomes.
departments, with each area framing informa- Proximal outcomes of interest include ac-
tion from their service perspective. The result curate beliefs about EH, self-efficacy in en-
is that, although families may end up with a acting risk reduction behaviors, and advance-
handful of pamphlets, they “lack the time and ment on the precaution adoption continuum.
energy to sort through the mass of informa- Instruments have been either adapted36 or
114 ADVANCES IN NURSING SCIENCE/APRIL–JUNE 2009

developed and pilot tested to measure these terventions in urban populations, the authors
outcomes.38 Distal outcomes include an in- state that “the contextual nature of exposure
crease in ERR actions and a decrease in the to stressors suggests that research and inter-
number or level of abnormal exposures. Ob- ventions will be more effective if they are con-
jective (direct observation) and subjective text specific.”41(p505) Other models emphasize
(self-report) instruments document a change the role of community and partnership ca-
in ERR actions. Exposure data are collected pacity in promoting environmental health and
by measuring levels of household radon (3- justice, paying particular attention to the role
day kit), carbon monoxide (monoxer), wood partnerships play in promoting relevant pub-
moisture equivalent (Protimeter), and water lic policy.42,43 Overall, these contributions ex-
contaminants (full well screen). Blood lead, plicate the dynamic nature of EH and the con-
salivary cotinine, and hair methylmercury tinued need for a response to EH risks through
samples measure changes in the level of ex- context-based ERR interventions applicable
posure. This delineation considers the tem- for family- or community-level research in ru-
poral sequence of risk reduction changes and ral areas.
can help guide the selection and timing of Nurses have historically conceptualized
study measures (eg, risk perception change EH through a social justice lens, emphasizing
scores). Although this approach is not unique advocacy and prevention.44 Dixon and Dixon
in its relevance to rural populations, the dif- proposed a translational EH framework based
ferentiation between proximal and distal out- on 4 conceptual domains: the physiologic,
comes allows for the inclusion of place-based vulnerability, epistemological, and health
outcomes that promote a more comprehen- protection domains. They noted the limited
sive understanding of rural EH problems. It impact of public health actions that focus
can also generate knowledge about how in- exclusively on the physiologic domain (eg,
formation impacts health outcomes through toxic potential of agents) stating that an
specific belief patterns. understanding of the physiologic domain is
necessary but insufficient to inform success-
ful risk reduction programs.32 Equally impor-
WHERE TERRA FITS: RELATED tant to translating EH is understanding how
CONCEPTUALIZATIONS ADDRESSING hazards are distributed among groups such
ENVIRONMENTAL HEALTH as the rich and the poor (the vulnerability
domain), how citizens find out about haz-
Several frameworks have emphasized EH ards, (the epistemological domain), and how
disparities, highlighting spatial concentra- people engage in EH (the health protection
tions of poverty/affluence and neighborhood domain). Recently, Postma summarized 3
cohesion. Race and place figured prominently relevant dimensions of the environmental
in Gee and Payne-Sturges’39 stress-exposure- justice movement for translational EH nursing
disease framework. The authors differentiated research. These include (1) reconceptualizing
between individual- and community-level vul- the “environment” to include the sociocul-
nerabilities, noting that both contribute to a tural context in which EH risks occur, (2)
cumulative burden of stressors, which can recognizing preexisting social networks as
amplify the deleterious consequences of EH a strengths-based approach to working with
exposures. Similar themes were apparent in politically marginalized groups, and (3) en-
the work of Schulz and Northridge,40 who ex- gaging community-based organizations and
amined social antecedents of environmental citizens alongside scientists in the research
inequalities. The ecological stress model by process.45
Parker et al incorporates stressors and inter- Via their position at the intersection of pub-
vening factors at multiple levels of an ecolog- lic policy and people’s personal lives, nurses
ical framework. Used primarily to guide in- are “ideally situated and morally obligated”
TERRA: A Conceptual Framework 115

to promote health through political advocacy including those that are not typically consid-
and efforts to influence public policy.46(p212) ered within the purview of EH (eg, Women,
The TERRA framework begins to address this Infants, and Children). Compared with the
call by building on previous conceptualiza- frameworks of EH disparities proposed by
tions of EH in the context of social justice Schulz and Northridge and Gee and Payne-
to explicate EH risks experienced by the Sturges, which both address a broad range
rural poor and appropriate risk reduction of macrolevel antecedents, our framework
strategies. includes social-cognitive factors that shape
how information is interpreted and applied in
the context of translational interventions.39,40
THE VIEW FROM ABOVE: USING TERRA These cognitive processes may be moderated
TO INFORM POLICY by inequities and EH risks; however, our goal
is to target specific parental behaviors that
The TERRA framework focuses on family- have the greatest potential to reduce expo-
level interventions in a rural public health sures to children.
context. Successful interventions inform pol- Our future work will explore the bound-
icy development. For example, our analyses aries of the framework, its relative fit or lack
to date suggest positive associations between thereof in more ethnically diverse communi-
the level of information that parents have and ties, and the extent to which its US-centric
the number of unsafe exposures found in the lens may or may not work in other parts
home. Such findings provide evidence of the of the world. We also plan to drill into the
need for public health policy changes at relationships between each concept, differ-
the state and local level (eg, requiring more entiating between sequential and iterative
comprehensive disclosure of EH risks [eg, mechanisms of change. Thus, in an effort to
radon] by landlords and realtors). understand how persons address EH risks
There is flexibility in the framework to in their daily lives, the TERRA framework
use community-based participatory research paints on a small canvas, yet can help inform
approaches to incorporate citizens’ voices broader and related discussions addressing
into the inquiry process (eg, by identifying EH policy and the scope of nursing practice.
relevant macrodeterminants in a particular
community) and integrating research findings
with political action. Similar ERR partner- CONCLUSION
ships, for example, have instituted routine
lead testing at the local health department Rural communities face new challenges
and Indian Health Service and helped stop from confined animal feeding operations,
the use of chat (mine tailings) in construction groundwater depletion, and agricultural
and on roads without proper containment.42 runoff. Recent initiatives addressing haz-
Community partners play a critical role in in- ardous waste cleanup and sustainable growth
terpreting findings locally and “taking knowl- are laudable; however, the resources needed
edge into the political change arena,” es- to diagnose and remediate past problems
pecially when institutional constraints make vastly outstrip those available. Complex
direct advocacy difficult.47,48(p318) problems require strategic solutions and
Use of the framework may also lead to the EH scientists have shown remarkable flex-
development of more efficient public health- ibility in reconciling toxicological and
care systems. By focusing on actions aimed at behavioral health perspectives to this end.
mitigating risks to multiple agents, health de- Embracing that complexity means that,
partments may be able to “de-silo”agent-based once again, “frameworks matter” because
programs (eg, lead) and incorporate broad- they “determine the research questions
based risk reduction into multiple programs, that are posed and investigated.”49,50(p212)
116 ADVANCES IN NURSING SCIENCE/APRIL–JUNE 2009

The TERRA framework proposes a broad The TERRA framework adds to the repertoire
conceptualization to inform EH research and of conceptual tools designed to advance a
is poised within its lifecycle to transition reflexive agenda for the next generation of EH
from constructivist roots to empirical testing. research.

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