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					2005–2006 Fellow Project   National Environmental Public Health Leadership Institute
          A Closer Look at the State of Iowa’s
               Swimming Pool Program
                                2005 - 2006


Environmental Public Health Leadership Institute Fellow:


 Joy Harris; MPH
Community Health Consultant,
 Iowa Department of Public Health
Lucas State Office Building
321 E. 12th St.
Des Moines, IA 50319
515-281-3377
jharris@idph.state.ia.us


Mentor:
Mark D. Miller, MPH, RS
Captain, U.S. Public Health Service
Senior Environmental Health Officer
Centers for Disease Control and Prevention
National Center for Environmental Health
Environmental Services Branch

Acknowledgements:
Tom Newton MPP
Division Director; Iowa Department of Public Health

Michael Magnant
Environmental Engineer, Senior; Iowa Department of Public Health




2005–2006 Fellow Project            National Environmental Public Health Leadership Institute
EXECUTIVE SUMMARY:

The Iowa Department of Public Health contracts with local health departments to provide
inspections of Iowa’s swimming pools and spas. At the state level the pool program has a
history of limited funding and staffing therefore making it less of a public health priority. While
national attention to recreational water illnesses and other public health effects of swimming
seems to be increasing, Iowa has not been able to capitalize on the opportunity to generate
attention statewide to the pool program. This article describes an evaluation of the program
using systems thinking tools. A summary of recommendations to improve the efficiency and
effectiveness of the pool program is also provided.


INTRODUCTION/BACKGROUND:

Prior to 1960, no written evidence exists that there were any guidelines or regulations for
swimming pools in the State of Iowa. In the early 1980’s the Department of Public Health began
to have some concerns about being the regulating authority for swimming pools. At that time,
the department felt the problems associated with the pool program included; a lack of specific
authority to regulate pools, a lack of resources to provide education and enforcement, and a
concern about the liability associated with inspecting pools without the specific authority to do
so. The department also had concerns about the lack of any regulatory authority dealing with
swimming pools in settings such as motels, health clubs, and mobile home parks.

In 1989 legislation was passed authorizing the department to regulate pools and spas and
establish fees. The initial plan called for the state to inspect most of the swimming pools across
the state. However, the department was never authorized to hire sufficient personnel to manage
the program. At its maximum staffing level, only three FTE’s were assigned to the state’s pool
program. In order to address these shortcomings, changes had to be made in the administrative
rules.

The first change came in 1990, when state required pool operators to become certified as a
Certified Pool Operator (CPO). And, in 1993 the department inserted wording to make it easier
for local public health agencies to contract to do the inspections. It was at this point that IDPH
took responsibility for plan review, initial inspection, and maintaining the swimming pool
registry. These activities are still the responsibility of the IDPH. (1)

Currently the swimming pool program is staffed by three part time FTE’s including an
environmental engineer, an environmental specialist, an administrative assistant. Funding for the
state program comes in part from partial retention of fees generated by the annual registration of
Iowa pools and spas and from fees charged to new facilities for plan review. Additional funding
is provided from the Centers for Disease Control and Prevention Public Health Services Block
Grant. These funds however, have not been sufficient to cover the current costs of the
swimming pool and spa program. (2)




   2005–2006 Fellow Project              National Environmental Public Health Leadership Institute
In addition to the funding issue, the state must also minimize the education and information gap
among local leaders and environmental health workers, as demonstrated in the 2001 report
Environmental Health: A Profile of Iowa’s Local Systems. When asked if they perceive
swimming pools and recreational waters as a serious environmental health risk in their county
the majority of local boards of supervisors, boards of health, and environmental health workers
said that the risk was not at all serious or somewhat serious. Most local boards of health said
that there was a somewhat serious risk. Similarly, the majority of environmental health workers
also said there was a somewhat serious risk. Furthermore, forty-one percent of environmental
health workers agreed that the swimming pool inspection program was effective in resolving the
problem. This data provides supporting evidence that local leaders and environmental health
workers could benefit from education about the potential risks of swimming pools and spas. It
also indicates that over half of the environmental health workers were not confident that the
program they had in place was effective at solving problems that may arise from swimming
pools and spas. (3)

Problem Statement:

The state of Iowa swimming pool and spa program is operating under-budget and is under-
staffed, and without full funding, pools and spas will continue to be vulnerable in the event of an
outbreak.

Behavior Over Time Graph:




                    #




                                                          Year
                              IDPH Funding

                              IDPH Staffing
                              Capacity of local dept.’s


                                          Figure 1




   2005–2006 Fellow Project                      National Environmental Public Health Leadership Institute
Tension: Decreased funding at the state level caused cuts at the state level which limit the ability
of the state to function efficiently and effectively as a contracting agency. At the same time,
local environmental health departments have been working to increase their capacity. Some
local departments have developed a database system to record pool data and have implemented
inspection programs by adopting their own policies and procedures for inspection, closure, and
follow-up.




Causal Loop Diagrams and applicable archetypes:

For the purpose of this report two archetypes are included. The first diagram shows the Shifting
the Burden Archetype. This is the most relevant archetype to describe the State of Iowa’s
swimming pool program. As depicted, when a recreational water illness (RWI) is reported, the
state quickly assesses the situation and directs the local environmental health department as to
what should occur next. At the state level, two groups become engaged in addressing the issue:
the Center for Acute Disease Epidemiology (CADE) and the Division of Environmental Health.
Once the situation has been handled state level employees quickly move on to the next thing that
needs to be addressed as do the local practitioners. Any lessons learned from the experience are
only of use to those immediately involved, and because the situation is taken care of a need for
improvements to the program is not seen. Therefore the program continues to function in the
manner depicted.




             EH & CADE step in – take care of
              illness – Activity occurs and is
                         forgotten




            Small # of people affected by RWI
              that occurs in local pool/pools
                                                                    Quick fix works- no outcry by the
                                                                      public, legislature, or county




               Redesign of pool services at
                       state level




   2005–2006 Fellow Project               National Environmental Public Health Leadership Institute
                              Figure 2: Shifting the Burden



Also relevant is the accidental adversaries archetype. The archetype depicts the relationship of
the state department of public health and the local department of public health. Both are working
to protect the health of Iowans. The state health department contracts with the local departments
to get the inspections done. In order to assure the effectiveness of the contracts personnel from
the Iowa Department of Public Health meet with local practitioners to review their program,
standardize inspectors, and require an annual report from the local practitioners. Local
practitioners collect fees for conducting swimming pool inspections and some have taken steps
to independently improve on their program by developing their own database, inspection form,
and follow-up process. Other local practitioners do not take these steps. The relationship is
adversarial because for those local departments who are able to make improvements, the
department does not recognize those and requires redundant reporting. The state also does not
reward their improvements in any way.




                                          State contracts with
                                           LHD to conduct
                                          swimming pool/spa
                                              inspections



                                                                  IDPH asks for
                                                                   duplicative
                       IDPH                                         reporting

    IDPH provides                     IDPH requires
       program                         reporting for
       reviews                         annual report

                                                                              LHD
                                                         LHD develops                      LHD collects
                        LHD not                          own database                         fees
                       delivering
                      same service




                                             Swimming pools and
                                               spas inspected


                                  Figure 3: Accidental Adversaries




   2005–2006 Fellow Project                 National Environmental Public Health Leadership Institute
10 Essential Environmental Health Services:

After looking closely at the swimming pool program improvements could be made in six of the
essential services.

   1. Monitor health status: IDPH should play a role in the collection of data regarding
      recreational water illnesses and distribute that information accordingly.
   2. Inform, educate, and empower people: In order to improve upon the current program it
      will be important to increase the department’s educational outreach regarding safe
      swimming.
   3. Develop policies and plans: The department needs to develop policies and plans
      internally in order to effectively manage contracts.
   4. Enforce laws: It is vital that swimming pool regulations are met in order to protect the
      safety and health of individuals who use Iowa’s swimming pools, spas, and recreational
      water parks.
   5. Assure a competent workforce: IDPH has a role to play not only in assuring that the
      environmental health practitioner is knowledgeable about providing a safe recreational
      water experience, but also in assuring that education is provided to pool operators about
      the importance of a safe swimming environment to prevent recreational water illnesses.
   6. Evaluate effectiveness, accessibility and quality: IDPH contracts with local
      environmental health departments to conduct swimming pool inspections and has the
      responsibility to evaluate the effectiveness, accessibility and quality of those contractors
      in fulfilling the obligations of the contract.


National Goals Supported

This project supports the CDC Health Protection goal of Healthy People in Healthy Places.
“The places where people live, work, learn, and play will protect and promote their health and
safety, especially those at greater risk of health disparities.” In an expansion of the goal
statement CDC further defines healthy places, part of that definition includes Healthy Travel
and Recreation. “Ensure that environments enhance health and prevent illness and injury
during travel and recreation.” (CDC goals) The CDC estimates that each year there are 360
million visits to recreational water venues. ( MMWR). In Iowa there are 2100 registered
swimming pools and spas with the Iowa Department of Public Health. Providing for a healthy
experience, by improving upon the current program, at those 2100 facilities is an important part
of protecting the health of Iowans.

This project also supports Goal I (Build Capacity) and Goal V (Communicate and Market) of the
Centers for Disease Control and Prevention document entitled “A National Strategy to Revitalize
Environmental Public Health Services.” Goal I Build Capacity states “improve and support
environmental public health services at the state, tribal, territorial, and local levels.” Goal V
Communicate and Market states “to improve communication and information sharing among
environmental public health agencies, communities, policymakers, and others and enhance the


   2005–2006 Fellow Project             National Environmental Public Health Leadership Institute
significance and understanding of environmental public health.” Strategies to improve upon the
current pool program would build the capacity of both the Iowa Department of Public Health and
local environmental health departments. Additional strategies focus heavily on the importance
of communicating the importance of preventing recreational water illness to the public, the
environmental health profession, and pool operators.

Recommendations also center upon improving the skills of Iowa’s local environmental health
workers in the areas of assessment, management, and communication as outlined in the
Environmental Health Competency Project: Recommendations for Core Competencies for Local
Environmental Health Practitioners. In order to make the changes outlined in this report both
state and local level personnel will have to modify how the swimming pool program is assessed
and managed as well as the messages communicated to all parties involved.



Project Logic Model:


     Inputs         Activities       Outputs            Short –term            Intermediate           Long-term
                                                        Outcomes               Outcomes               Outcomes


   State level      Interviews       # of               List of                                       Established
   personnel        with state and   interviews         recommendations          Changes to           data
   willing to       local            conducted          made available           local                collection
   address          practitioners                                                contracts            of risks
                                                                                 reflective           data re.
                                                                                 of short-            morbidity
                                     % of pools         Communication            term                 and
                                     reviewed           to local                 outcomes             mortality
   Data             Collection       by fellow          contractors re.                               associated
   availability     of data by                          potential “critical                           with
   at county        fellow                              factors”                                      swimming
   and state                         # of critical                                                    pools
   level                             violations                                  Increased
                                     noted                                       attention to
                    Literature                                                   swimming             Swimming
   Dedicated        Review                                                       pool                 pool
   time to                                                                       program at           program at
   project                           Local leaders         Raise awareness       the state            the state
                                     aware of              of swimming           level                level is
                    Presentation     project able to       pool program                               continually
                    of process and   disseminate           among local                                evaluated
   Need has         findings to      initial findings      practitioners                              and
   been             capacity                                                                          improved
   identified       building                                                                          upon as
   by local         workgroup                                                                         needed
   leaders                                                                       Reduced
                                                                                 swimming
                                                                                 pool
                                                                    Goal
                                                                                 morbidity
                                                                                 and
                                                                                 mortality




PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES:



   2005–2006 Fellow Project               National Environmental Public Health Leadership Institute
Program Goal
Reduce morbidity and mortality associated with swimming pools in Iowa.

Health Problem
Risk factors with the potential to increase morbidity and mortality in pools are ever present.

Outcome Objective
Risk factors associated with morbidity and mortality in pools will be reduced.

Determinant
Risk factors involved in swimming pools are quite varied; at this point the potential determinants
are unsubstantiated.

Impact Objective
Swimming pool programming at the state level will be preventative in nature.

Contributing Factors
   1. Lack of resources for the swimming pool program.
   2. This program has not caught the attention of state leaders due to a negative situation.
   3. The Iowa Department of Public Health has historically been under funded and
       understaffed to perform this program.
   4. The number of swimming pools and water parks in Iowa continues to increase.

Process Objectives
   1. Identify gaps in the delivery of the swimming pool program at the state level.
   2. Identify needs in local environmental health departments to improve upon the delivery of
       swimming pool programming.
   3. Identify positive ways to impact the program without devoted funding or staffing.


METHODOLOGY:

As funding and staffing is limited this fellow was able to take a cursory glance at the swimming
pool program. At the state level when this project was initiated there was only one employee
committed on a part-time basis to the pool program in particular. His responsibilities included
direct provision of inspections in some Iowa counties, approval of each new swimming pool to
be built in Iowa, an inspection when those new pools open, and working with local
environmental health contractors to assure that inspections were being conducted effectively.

Upon gaining this knowledge the fellow gained access to records available at the state level for
the pool program. Records are stored in the possession of several different staff members in the
Division of Environmental Health. Not all records are present, and many are incomplete.

At the local level this fellow discovered several different processes in place to complete
swimming pool inspections. Each inspected the same elements, but some conducted monthly
water tests as a courtesy, others never looked at pool documented records because they felt that


   2005–2006 Fellow Project              National Environmental Public Health Leadership Institute
the records kept often are not reflective of any problems a pool might have. This fellow
surveyed local environmental health officers who are inspectors of pools about what the “critical
violations” (to borrow a phrase from the food industry) of swimming really are. A consensus
was not reached in the informal survey. Most inspectors believed that with the dangers involved
in swimming pools that each inspection criteria is critical to assuring the public’s health.

As part of this experience this fellow also attended Certified Pool Operator training and became
a Certified Pool Operator. At the training session trainers only minimally discussed the health
implications of the mishandling of a pool, and the potential dangers to health inherent with a
swimming pool.

Finally, due to this fellow’s interest in the program any swimming pool reports required by the
department were given to this fellow to file. The majority of contracts did not submit the
required annual report, and the department does nothing with the information given.


RECOMMENDATIONS AND NEXT STEPS:
  1. It is the Department of Public Health that advertises to many the opportunities available
     to attend certified Pool Operator Training. As this relationship already exists the
     department could take steps to provide further educational materials to trainers and
     emphasize the importance of the role of the pool operator in preventing illness.
  2. The Department of Public Health could also provide a train-the-trainer program for
     inspectors that they could then use in their contacts with operators during the inspection
     also covering the importance of the operator’s role in providing a safe swimming
     environment.
  3. The Department of Public Health currently collaborates with other groups to provide
     training in the area of onsite wastewater and water quality. Similar collaborative
     relationships should be sought to provide training on swimming pools and spas for
     inspectors. Swimming pools and spas should also be covered as part of the annual New
     Sanitarian Training, currently they are not.
  4. Press releases regarding safe swimming practices and other media opportunities to
     provide education to Iowans should be taken advantage of.
  5. In the long term the department may want to consider developing a statewide database of
     swimming pools and spas.
  6. Internally the department needs to develop a filing system of pool reports.
  7. Finally the department needs to assure reporting requirements are met and should develop
     a systematic audit of contract documents submitted to the department that could be
     conducted on a staggered schedule or on a regular schedule if additional staff time
     becomes available.

 EXPECTED OUTCOMES:

With dedicated time and funding the swimming pool program could be improved upon. Without
time and funding the program will continue to take a backseat to other public health programs.
However, there are several ways that the program could be impacted without a lot of additional
time and with no additional funding. Educating the public, business industry, operators, and



   2005–2006 Fellow Project             National Environmental Public Health Leadership Institute
regulators will be a key step in developing the program further. The department has made
available some additional staff time to the swimming pool program since this project began, and
the fellow has implemented an internal filing system. A press release about health swimming
habits was completed prior to the 2006 outdoor swimming season and several newspapers and
television statements across Iowa picked up the message. In March 2007, the department will
also be providing to local environmental health practitioners a policy and procedure development
manual that will include policies and procedures regarding the swimming pool program.


LEADERSHIP DEVELOPMENT OPPORTUNITIES:


Joy Harris

As a participant in the Environmental Public Health Leadership Institute I have had the privelege
not only to improve upon my own skills and abilities but to learn from my peers as they develop
their skills and abilities. While leadership has many common themes it is important to recognize
that while carrying out activities each leader is uniquely able to address an issue or problem
based on their own characteristics. I am now much better equipped to work with other leaders
having a better understanding of myself and having had the opportunity to work my peers, each
with their own unique abilities.




   2005–2006 Fellow Project             National Environmental Public Health Leadership Institute
ABOUT THE EPHLI FELLOW(s)

Joy Harris is the project coordinator for the Iowa Department of Public Health’s
“Building Environmental Health Capacity” grant. Iowa is currently in its fifth year of
funding from the National Center for Environmental Health to address capacity issues in
Iowa’s environmental health programs at both the state and local levels. Ms. Harris has a
Master of Public Health degree from Des Moines University. She received a dual
bachelor’s degree in occupational therapy and psychology from St. Ambrose University.


REFERENCES

1. Personal communication with Michael Magnant 9/2/2005
2. Personal communication with Tom Newton 5/15/2006
3. Environmental Health : A Profile of Iowa’s Local Systems, Nov. 2001 by Jacqueline
M. Comito.
4. A National Strategy to Revitalize Environmental Public Health Services, Centers for
Disease Control and Prevention, Sept. 2003.




2005–2006 Fellow Project            National Environmental Public Health Leadership Institute

				
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