The Inspection-Based Enforcement Approach to Noncompliance................. 1
Support for the Inspection System.......................................... 4
A Critique of the System................................................... 9
Considering Objections to Change........................................... 10
The Profession's Development and Mindset................................... 12
Over Emphasis on Legal Enforcement......................................... 20
Effects of Fear Arousal and Anxiety........................................ 23
Fear Arousal Summary....................................................... 34
Critique: Poor Design of Education and Communication Efforts............... 36
Considering a New Paradigm................................................. 45
Section Summary: Learning Principles....................................... 51
The Health Belief Model.................................................... 52
Implementing Changes: Introduction to Intervention Design.................. 79
Designing the Intervention................................................. 81
Using the Model During Intervention Design................................. 86
Making a Persuasive Argument for Change.................................... 90
Actual Versus Perceived Control............................................ 103
Validity Questions......................................................... 106
Summarizing the Need for Change............................................ 108
Steps to Implementation.................................................... 110
Final Summary.............................................................. 122
Appendix of Figures........................................................ 
Appendix 1: Intervention Points in the Health Belief Model................. 127
Appendix 2: Points Where Sanitarians Can Influence Decision Making......... 129
Appendix 3: Evaluation Interviews.......................................... 130
Appendix 4: Evaluation Checklist........................................... 133
Appendix 5: Sanitarian's Checklist......................................... 135

Excerpt

CHAPTER 1

THE INSPECTION-BASEDENFORCEMENT APPROACH TONONCOMPLIANCE

The inspection-based enforcement system has positive, necessary aspects,aspects that will make change, however important, slow and incremental.Here is a synopsis of the process, provided for non-sanitarians and toestablish a common ground for discussion.

The sanitarian's task is to evaluate sites and facilities for public healthrisk factors (the latter are established by legal mandate, varying degreesof severity and epidemiological association with environmental concerns[illness, contamination]) and take action to abate those risks. Availabletime and resources are oriented around documenting risk conditions andproducing a complete, objective report of these findings. Data about thesite is gathered using a wide range of equipment such as meters, test kits,thermometers, measuring tapes, levels and probes; computers are used todocument findings and create a report. Last, site personnel are observedon the job and interviewed, to determine their knowledge, skills andabilities to apply safe sanitation procedures.

The completed site report is then discussed with the client, includingaspects such as (a) the site's overall sanitation status; (b) problems andtheir solutions, those cited on the report and developing trends thesanitarian has observed; (c) compliance times; and (d) repercussionsof continued noncompliance (e.g., more frequent site visits, hearings,fines, tickets, court actions). Other notifications may be issued, such asplacards or tags, if the site's status is unacceptable.

While the sanitarian specifies the end result for each citation (e.g.a floor in good repair, clean hands, clean and sanitized equipment),a specific comprehensive method or process (e.g. linoleum, quarryor ceramic tile, texture and type of wall paint, precise methods forwashing hands or cleaning equipment) may not always be stated. Suchdescriptions take space on the report, take time to write and may excludea method better suited for the client and site. Too much detail couldcost the facility added expense, yield a worse result or give the client anexcuse to delay compliance. This is an important point in the complianceprocess; clients and site personnel must be educated and experiencedenough to institute changes that are legal, correct and best suited fortheir facility.

After the initial site evaluation, the sanitarian monitors thesite's progress toward compliance, using site visits, telephone calls,correspondence and office conferences, until acceptable sanitation statusis achieved. Secondary functions to the site visit include consultations,conferences, educational programs and other resources, to clarify reportresults and corresponding coping strategies. If return visits demonstratea significant risk reduction, the sanitarian moves to another site andclient. If, however, items of significant risk continue to be cited, returnsite visits occur, using progressively more severe legal remedies (tickets,fines, license revocation, injunctions) until these items are resolved. Ifnecessary, action is taken to remove the offending site or facility fromoperation. This is an entirely different process, involving additional legalhearings, the gathering of evidence, and the writing of reports.

Considerable time, training, and resources are devoted, not only toproducing an objective, comprehensive report but also to maintain andcalibrate the equipment needed for the job, Note that this equipment isvital, not just to gather data, but to produce an accurate report with legalstanding.

Aside from the legal mandate, and the sanitarian's essential roleas environmental protector, this report is important for political,professional and legal reasons. Detached observation, along with theuse of progressively more complicated equipment, gives the sanitariancredibility as a scientist and technician. A complete and comprehensivereport is a more reliable legal document. The public sees such adocument as evidence that tax dollars are used constructively. The failureto produce such a report could result in legal liabilities, citations forprofessional malfeasance, or much worse, the loss of operating funds dueto a failed audit. The time, resources, and professional pride involved increating this "product" reflect the investment health agencies have in thissystem.

Note: This book makes frequent references to repeat contact withclients. It might appear, therefore, that single visit services such as waterwell and septic system evaluations would not apply. That is not the case,however. Repeat contacts are not just site visits but may include anycontact between the client and health agency personae (printed literature,media releases, communication campaigns, school system curricula, localfairs, exhibitions or festivals, and word of mouth reports from otherclients or visits to nurses, doctors, dentists, hospitals or clinics). Any ofthese contacts will influence the health agency's credibility as well as theclient's motivation to act, perhaps even more so than direct contact witha sanitarian.

SUPPORT FOR THE INSPECTIONSYSTEM

The description above illustrates the considerable pride and investmentsanitarians have in what they see as objective, balanced, and scientificwork. Most sanitarians working with public agencies do so to servethe community; if money rather than professional pride was the mainreason for working, private industry offers sanitarians a larger income.Therefore, suggestions of bias or harassment receive a dim view, similarto a patient's questioning of a physician's regimen. The sanitarian'sacademic training and professional orientation both advocate a balancedholistic environmental approach to problems: sanitarians believe thatthey are reflecting that ideal in their work (Fig. 1).

To some extent, their belief is supported: there is compellingevidence of this approach. Most public health regulations are clear,logical, well publicized, and, with the exception of more complicatedupgrades to structure or equipment, easily resolved through behavioralchange. There are education programs, media releases, newsletters, andpamphlets to explain the rules. Many clients comply without legalpressures, indicating a good understanding of public health requirementsor at least an effective use of information about them. The inspectionprocess is the same approach used by other civil authorities (e.g., police,fire, municipal) and therefore is familiar to the community. If there areto be errors in the use of the system, it certainly appears more prudent tobe too severe and be certain imminent high-risk violations are found andabated. Tentativeness caused by being familiar with clients or discussingimprovements could inadvertently create confusion and encouragenoncompliance.

More anecdotal supportive evidence comes from field experience.Regular, repeated observations of high risk concerns lead sanitariansto believe that a client's excuses must be irrational or inexplicable, i.e.psychological in nature. This makes some sense: thinking about thecosts and potential impact of food borne illness, who can conceive ofa rational explanation for statistically significant causal factors such asimproper hand washing?

Yet, these repeat occurrences appear to indicate a significantdisconnect between site personnel and accepted scientific knowledge.When confronted with these concerns, clients are frustrated, apologeticand mystified about their occurrence; this suggests, again, that no goodexplanation exists, at least not to the client and certainly not to thesanitarian. From these observations evolves the idea that either the causesare psychological and inexplicable or simply recalcitrant, i.e. not the faultof inefficacious environmental health services.

Compliance with infrastructural defects (e.g., floors, walls, orequipment in disrepair) is more complicated than high risk-behavioralconcerns, due to strong causal links to environmental factors such asresources, time, cost or availability. The most motivated client may findbarriers to change overwhelming and out of their control. High-riskbehavioral concerns, however, while certainly linked to environmentalbarriers, are much less resource dependent. Proper hand washing,utensil washing, and food storage are three commonly accepted hygienicpractices, at home or in restaurants. From the sanitarian's perspective,the rational approach to this type of violation should be staff trainingand routine monitoring of the problem. Since this does not requirea significant investment of resources, at least from the sanitarian'sperspective, training should happen and compliance should occur. Onthat basis, noncompliance must be irrational and recalcitrant behavior.(This book will try to suggest a different approach).

Furthermore, the sanitarian's primary function, defined and drivenby legal mandate, is always risk abatement, not analysis. This function islocked in by legal mandate and community demand. Documentation andcorrective action remain the foundation of the legal mandate and matchingfunds requirements, not the analysis of noncompliance. If a sanitarian isintent on learning a client's motivations, more time must be generatedduring the site visit, not an easy proposition. While some sanitarians persistin this effort, administrators generally discourage this effort as moot, a wasteof time and resources. Since causes of noncompliance must be irrational andrecalcitrant (at least under the present system), analysis is futile. Analysisdoes not contribute anything toward risk abatement. To its advocates, theinspection system has worked well to limit the impact of overt public healthproblems; any noncompliance not covered by existing enforcement can beaccredited either to the client's recalcitrance or the need for more stringentinspections.

The inspection-based system and its corresponding view ofnoncompliant behavior as recalcitrant are both supported by publichealth administrators, the public, the sanitarian's anecdotal fieldexperience, and the literature; thus sanitarians are reluctant to changethe system. In addition, external audits and associated budget dollars arelinked to the system.

Even if these audits did not exist, however, public health professionalswould still be comfortable with the system. The public and many clientssee the system as an efficient use of tax dollars and a fair, equitableadministration of the law. Historically, sanitarians have been expected tocontain the spread of imminent public health hazards (e.g., tuberculosis,community disasters), as in the case of epidemics or communitywidecontamination.

The public expects this protective function and looks for legalactions as an effective use of tax dollars. A comprehensive site report ofsanitary violations feeds into this expectation. Anecdotal field experienceshows the citation of severe sanitation risks, providing enough evidenceto support this system. Finally, the system provides respect for thesanitarian's professional development as a scientist and technician. Eachsite report supplies a viable legal document and establishes credibility andrespect for the sanitarian. (Professional respect is vital when competingfor a portion of a shrinking public health budget.)

Public health professionals rarely cite literature to support their system;this may explain why assumptions about noncompliance are based on fieldexperience, not on behavioral science. Conceptual explanations, however,resemble psychodynamic theory. This theory states that noncompliant or"deviant" behavior is attributed to a "manifestation of the dynamic interplayof inner forces, most of which operate below the level of consciousness."Causes of noncompliance are thought to be psychological, hidden andunavailable for further inquiry. The sanitarian's perspective is based onoutcome, not cause (the cause in this case, by definition, is within theindividual, unavailable for inquiry). This fact forces further use of legalenforcement to influence outcome.

A CRITIQUE OF THE SYSTEM

The preceding section describes necessary parts of the inspection- andenforcement-based system, why it seems perfectly justified, and howit has become entrenched in the public health psyche. This lengthydiscussion was needed to illustrate the deep investment sanitarianshave in the system and the difficulty of subsequent change, howeverwarranted. As with any attempt at change, there will be individualsreluctant to endorse it. In line with behavioral science concepts, potentialobjections to change must be addressed. After that, we can examine whythese changes are important and necessary.

CONSIDERING OBJECTIONS TOCHANGE

As a precursor to a critique of the system, we need to consider whypublic health professionals might not endorse a systemic change (later,there will be specific changes to consider). There are several possiblereasons: (a) there is no research to suggest there is a problem; (b) if therewere problems, solutions must originate with legislators, not sanitarians;and (c) there has not been prior criticism of the system.

It is true that there is no exploratory research; this is unlikely tochange until a crisis highlights problems with the system. The emphasisof current environmental health service is retroactive, not proactive. Thisis due to legislative mandate, budget constraints, sociopolitical pressuresand the nature of the science itself. Administrators are reluctant to budgetexploratory research that is expensive to conduct and difficult to justify.Environmental concerns are subclinical or chronic, not acute as with thework of doctors or nurses. Any documentation is often biased, relying ona self-interested client's report or on anecdotal evidence. Since problemsare difficult to document, the not entirely unreasonable assumption isthat they do not exist.

Legislative mandates restrict the sanitarian's options duringinspections, locking in certain enforcement-based components to theinspection and written report (see "The Inspection-Based EnforcementApproach"). While program funding is linked to satisfying thesemandates, however, these restrictions should not be an excuse to avoidchanges to the system or to resist screening for developing trends. Acertain amount of reluctance is understandable; however, there stillis ample room within the existing system to incorporate the changessuggested in this book. Once these improvements are instituted anddocumented by research, public pressure may cause legislators to amendthe system.

While there is little concrete data to use in program evaluation, thereis compelling anecdotal information and personal experience to suggestthe need for change. Many individuals have experiences in which they actcontrary to legal mandates, friends' advice, or scientific research. Otherfactors or information influence their decision. Similarly, sanitarians seeclients who, faced with legal action, still are unable to rectify violations:these people appear reasonable and sincere yet cannot make the requiredchanges. They simply do not fit the expected "recalcitrant" stereotype.

Finally, critics use the absence of supporting data or research tosuggest that these ideas are overemphasized and unrealistic, and are thework of "ivory tower" academics. However, if this discussion is new tosanitarians, it is not new to health educators or behavioral scientists.In 1975, Goldsmith and Hochbaum observed the shortcomings ofenvironmental protection, stating that

Neither strict enforcement of environmental codes norconcerted consumer education has prevent people fromsubjecting the environment to continuous insults, eventhough these insults will be to their ultimate detriment. Yetthese measures have been the main ones on which publichealth environmentalists have relied in their environmentalprotection efforts.

The authors suggest a reason why these `insults' continue and whysanitarians do not change their approach: "they (sanitarians) have beentrained to deal primarily with the symptoms or the results ... rather thanwith the determinants of human behavior." They go on to decry the lackof available information for motivated clients wishing to comply, statingthat "environmental health agencies ... have all too often made informationavailable only to those who know where to obtain it and are willing to makethe effort to do so." This would suggest that some changes and exploratoryresearch are needed to explore both behavioral science applications and thenature of consumer education.

(Continues...)

Excerpted from Environmental Health Noncompliance by David Mikkola. Copyright © 2013 by David Mikkola, R.S., M.P.H.. Excerpted by permission of AuthorHouse.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Lawfulness, fairness and transparency;
Purpose limitation;
Data minimisation;
Accuracy;
Storage limitation;
Integrity and confidentiality.
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a copy of your personal data;
that inaccurate data is rectified; and
that your personal data is, in certain circumstances, erased or restricted.
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We collect and process data for the following reasons:

personal data collected and created in relation to our selling books and other items; and
personal data relating to our people (which means those people working for our company, or providing services to us, or potentially working or providing services to us, including employees, consultants, temporary or casual workers and contractors).
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Selling books and other items
COLLECTION:
We will collect personal information which may include names, addresses and other information for our customers. This will be done for the management of the commercial relationship with our customers.

We may collect this personal data from you directly, and also from third parties, including publicly available third party sources. Additional personal data will be collected as it is created by or supplied to us in the course of anything we do for you.

USE:
We will use the personal data in the course of making sales and to comply with requirements that we are required to undertake.

We will only use your personal data when the law allows us to. Most commonly, we will use your personal data in the following circumstances:

in performance of a contract (the agreement to sell books and other items); and/or
compliance with a legal obligation; and/or
vital interests of the data subject; and/or
where it is necessary for our legitimate interests (or those of a third party) and your interests and fundamental rights do not override those interests.
We may also use your personal data in the following situations, which are likely to be far less common:

where we need to protect your interests (or someone else’s interests);
where it is needed in the public interest or for official purposes.
DISCLOSURE:
We may share personal data with third parties as is necessary in the sale of books and other items, including to third party providers who deliver services to support the operation of our company.

In respect of all disclosures of personal data, we will only share the personal information which is necessary for the particular purpose for which it is provided, or where we have another legitimate interest in doing so, and we will ensure that the personal data is appropriately protected.

RETENTION PERIOD:
We will keep personal data only for as long as is necessary to fulfil the purposes for which we collected it, including for the purposes of satisfying any legal, accounting or reporting requirements. Normally, our retention period for personal data collected for this purpose is a minimum of 6 years after the end of the period that we are selling books and other items.

Our people
COLLECTION:
We will collect names, addresses, contact details, education and employment history, identity and other background checks (which may include appropriate criminal and financial checks and confirmation of the right to work in the UK), marital status and information on next of kin and dependents, financial information (such as bank details and NI numbers), date of birth, gender, a copy of your passport and driving licence, performance information and compensation history, recruitment information (including references), salary, benefits, pension and annual leave information, disciplinary and grievance information, photographs, information about your use of our information and communications systems and CCTV footage or other information obtained through electronic means.

We may collect and use special categories of personal data as required in the carrying out of obligations and exercising specific rights of us or the data subject in the field of employment. This may include information relating to matters such as health, racial origin, religious belief and offences or alleged offences.

Personal data may be collected from you during the selection process (for example via your application form and CV) and during your employment (including holiday forms, expense claims, performance reviews, any disciplinary or grievance processes), or from third parties, including referees, health service providers, background check providers.

USE:
Personal data of our people will be used for HR administration and management, both in respect of the selection of people to work for us (including suitability, eligibility and/or fitness to work), and those who do work for us, to include learning and development, disciplinary and security (of people, offices and data) requirements, providing and liaising with benefits providers, business management and planning (including accounting and auditing), paying you and dealing with tax and NI deductions, assessing and deciding on salary reviews and compensation, conducting performance reviews and managing performance, dealing with legal disputes involving you or others, preventing fraud, monitoring your use of our information and communications systems, ensuring compliance with our policies, and equal opportunities monitoring.

We will only use your personal data when the law allows us to. Most commonly, we will use your personal data in the following circumstances:

In performance of a contract with you; and/or
compliance with a legal obligation; and/or
vital interests of the data subject; and/or
where it is necessary for our legitimate interests (or those of a third party) and your interests and fundamental rights do not override those interests.
We may also use your personal data in the following situations, which are likely to be less common:

where we need to protect your interests (or someone else’s interests);
where it is needed in the public interest or for official purposes.
In respect of all disclosures of personal data, we will only share the personal information which is necessary for the particular purpose for which it is provided, or where we have another legitimate interest in doing so, and we will ensure that the personal data is appropriately protected.

In respect of special categories of personal data, we may process this in the following circumstances:

in limited circumstances with your explicit written consent; and/or
where we need to carry out our legal obligations and in line with our policies; and/or
where it is needed in the public interest (such as for equal opportunities monitoring or in relation to our occupational pension scheme), and in line with our policies; and/or
where it is needed to assess your working capacity on health grounds, subject to appropriate confidentiality safeguards.
Less commonly, we may process this type of information where it is needed in relation to legal claims or where it is needed to protect your (or someone else’s) interests and you are not capable of giving your consent, or where you have already made the information public. We may also process such information about our people (or former people) in the course of our legitimate business activities with the appropriate safeguards.

The special categories of personal data may be used in the following ways:

in relation to leaves of absence, to comply with employment and other laws;
in relation to your physical or mental health, or disability status, to ensure your health and safety in the workplace and to assess your fitness to work, to monitor, manage and administer benefits and absences;
in relation to your race, national or ethnic origin, religious, philosophical or moral beliefs, or your sexual life or sexual orientation, to ensure meaningful equal opportunity monitoring and reporting.
DISCLOSURE:
Personal data may be transferred to service providers who support the operation of our business (such as payroll service providers), to other third parties reasonably necessary in the conduct of our business (including insurers, professional advisors, regulators). These third parties may be acting as processor, or controller of personal data in their own right.

RETENTION PERIOD:
We will keep personal data only for as long as is necessary to fulfil the purposes for which we collected it, including for the purposes of satisfying any legal, accounting or reporting requirements. We will normally keep personal data of applicants who we do not employ for six months after we receive it.

We will keep personal data of employees throughout your employment and normally for a minimum of six years after your employment ends.

Changes to your personal data
It is very important that the personal information that we hold about you is accurate and current. Please tell us if your personal information changes during your relationship with us.

Data Security
We have put in place measures to prevent your personal data from being accidentally lost, used or accessed in an unauthorised way, altered or disclosed. In addition, we limit access to your personal data to those of our people and other third parties who have a business need to know. They will only process your personal data on our instructions and where they have agreed to treat the information confidentially and to keep it secure. We have put in place procedures to deal with any suspected data security breach and will notify you and the ICO of a suspected breach where we are legally required to do so.

Where we store your personal data
We principally store data, both electronically and on file, at our office.

Personal data may be transferred outside of the EEA by processors acting on our behalf. For transfers to countries not considered adequate by the EC, we will ensure that personal data is adequately protected, as required by the GDPR. This would include by use of the Standard Contractual Clauses adopted by the EC to protect personal data.

Your rights
Under certain circumstances, you have the right by law to request:

access to your personal data. This enables you to ask to receive a copy of the personal data that we hold about you and to check that we are lawfully processing it.
correction of the personal data that we hold about you.
erasure of your personal data.
object to processing of your personal data where we are relying on our legitimate interest and there is something about your particular situation which makes you want to object to processing on this ground. You also have the right to object where we are processing your personal information for direct marketing purposes.
restriction of processing of your personal data.
transfer of your personal data to another party.
Links from our website
Our website may, from time to time, contain links to and from the websites of third parties that we permit to make such links. If you follow a link to any of these websites, please note that these websites have their own privacy policies and that we do not accept any responsibility or liability for these policies. We recommend that you check these policies before you submit any personal data to these websites.

CHANGES TO THIS PRIVACY POLICY
Any changes we may make to our privacy policy in the future will be posted on our website, so please ensure that you are viewing the correct version.

Please contact us if you have any questions, comments or requests regarding this Privacy Policy.

Last amended May 2021.

Environmental Health Noncompliance

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