Environmental Pollution as Community Health Need: NYS Hospital Assessment and Response in Community Benefit Processes

This entry is part 7 of 11 in the series Nov 2023

Nearly 19 percent of NYS nonprofit hospitals sampled identify environmental pollution as a priority community health need however, once identified, hospitals do not go on to address these needs.

“Human beings create the environments that shape the course of human development…this agency makes humans – for better or for worse – active producers of their own development.” (Urie Bronfenbrenner, 2005, xxvii)1.

The paradigm of health care for US Hospitals has expanded to include a health determinants approach with a commitment to population health outcomes and to improving health equity2-6. The matter of hospital engagement with environmental pollution is an important question of policy and practice. A growing body of evidence indicates the substantial impact of environmental pollution on human health and on racial and economic health disparities7-20.

Click to Read the Article

To move this issue into greater systemic and institutional policy discourses, it is important to establish some understanding of the current state of hospital engagement with environmental pollution as a community health concern. We responded to this need with a preliminary step of inquiry in investigating the extent to which New York State hospitals incorporate environmental pollution in their assessment of and response to community health needs as part of community benefit processes.

Community Benefit is both the idea of a social contract by which nonprofit hospitals will return good to the community beyond paid services and a manifestation of this idea in a particular set of federal community benefit regulations for nonprofit hospitals. These regulations include the requirement of nonprofit hospitals to perform triennial community health needs assessments and to document responses to these needs, or to provide a rationale for no response. We focused within community benefit processes because this is an emerging area in which hospitals are engaging community health improvement and other activities to address determinants of health21-25, and one which holds some consistency in documentation requirements across institutions. Additionally, the activities of hospital community benefit, and the implications for health, is a growing area of scholarship to which our paper contributes.

Our inquiry was a retrospective observational study of hospital community benefit processes as discerned through publicly available hospital associated community health needs assessment reports, associated implementation plans, and related IRS filings. We drew our sample from a sampling frame of NYS nonprofit, private, non-specialty hospitals utilizing probability sampling at the county level. This resulted in inclusion of 32% of all NYS private nonprofit hospitals (n = 53) distributed across 37% of NYS counties. We asked: do nonprofit hospitals in NYS assess, identify, or respond to environmental pollution as part of community benefit processes? We also investigated for relationship between the content of hospital stated mission with presence of assessment, identification, or response to environmental pollution. Environmental pollution was operationalized as outdoor air, soil, or water pollution.

We found that, for hospitals in our sample, 60.4% (95% CI, 0.46- 0.74) engaged in some assessment of environmental pollution as a community health need. Of the sample, 18.9% (95% CI, 0.09 – 0.32) identified a form of environmental pollution as a priority substantial community health need. However, no hospital went on to plan or take action on environmental pollution as part of community benefit activities. In additional analysis we found that hospitals having social justice or commitment to the poor or underserved as an element of stated mission had over 10 times greater odds of having evidenced some assessment of environmental pollution in the community health needs assessment.

Our study identifies that NYS hospitals do, to a substantial extent, assess and identify environmental pollution as a community health need. The study also identifies a lack of hospital action when such needs are identified in community benefit processes. Our study brings the concern of hospital engagement of environmental pollution to the community benefit policy and practice scholarly discourse. The findings point to opportunity in building on existing hospital engagement with assessment and prioritization of environmental pollution as a community health need. Importantly, the findings also identify an absence of hospital action when environmental pollution has been identified as a community health need. If this gap were to be addressed, a major negative contributor to health and health equity could be better improved. It will be important to identify barriers and facilitators to such action and to develop policy and practice pathways by which hospitals may join with others to address environmental pollution as a health determinant. Such movement is relevant not only to researchers and to hospital community benefit administrators but also to those who might collaborate with hospitals in community health improvement – public health departments, community organizations, social justice advocates, nurses (with an ethos of environment and health), and all interested health professionals.


  1. Bronfenbrenner U. (Ed.). 2005. Making human beings human. Thousand Oaks, CA: Sage.
  2. American Hospital Association. Leadership toolkit for redefining the H: Engaging trustees and communities.2015. https://www.aha.org/system/files/2018-01/redefining-h-with-appendix.pdf Accessed Oct 1, 2020
  3. Begun JW, Potthoff S. Moving upstream in US hospital care toward investments in population health. J Healthc Manag.2017;62(5):343-353. 10.1097/JHM-D-16-00010
  4. Hester JA, Stange PV, Seef LC, Davis JB, Craft CA. Towards Sustainable Improvements in Population Health: Overview of Community Integration Structures and Emerging Innovations in Financing [CDC Health Policy Series No. 2]. Atlanta, GA: Centers for Disease Control and Prevention:2015. CDC Health Policy Series No.2 Accessed Sept. 30, 2023
  5. Perez B, Szekendi MK, Taylor-Clark K, Vaughn J, Susman K. Advancing a culture of health: Population health programs in place at essential hospitals and academic medical centers (2012-2014). J Healthc Qual. 2016;38(2): 66-75. 10.1097/JHQ.0000000000000032 PMID: 26918809
  6. Robert Wood Johnson Foundation. Time to act: investing in the health of our children and communities: recommendations from the Robert Wood Johnson Foundation.2014; https://www.rwjf.org/en/library/research/2014/01/recommendations-from-the-rwjf-commission-to-build-a-healthier-am.html Accessed September 30, 2023.
  7. Fuller R, Landrigan PJ, Balakrishnan K, Bathan G, Bose-O’Reilly S, Brauer M, Caravanos J, Chiles T, Cohen A, Corra L, Cropper M, Ferraro G, Hanna J, Hanrahan D, Hu H, Hunter D, Janata G, Kupka R, Lanphear B, Lichtveld M, Martin K, Mustapha A, Sanchez-Triana E, Sandilya K, Schaefli L, Shaw J, Seddon J, Suk W, Téllez-Rojo MM, Yan C.  Pollution and health: a progress update. Lancet Planet Health.2022; 6(6):e 535- 547. doi: https://doi.org/10.1016/S2542-5196(22)00090-0. PMID: 35594895.
  8. Di Q, Dai L, Wang Y, Zanobetti A, Choirat C, Schwartz JD, Dominici F. Association of short-term exposure to air pollution with mortality in older adults. JAMA.2017;318(24):2446-2456. doi:10.1001/jama.2017.17923
  9. Bekkar, B., Pacheco, S., Basu, R., & DeNicola, N. (2020). Association of air pollution and heat exposure with preterm birth, low birth weight, and stillbirth in the US: A systematic review (vol 3, e208243, 2020). JAMA Netw Open, 3(7) doi:10.1001/jamanetworkopen.2020.14510
  10. Yazdi MD, Wang Y, Di Q, Requia WJ, Wei Y, Shi L, Sabath M, Dominici F, Coull B, Evans, JS, Koutrakis P, Schwartz JD. Long-term effect of exposure to lower concentrations of air pollution on mortality among US medicare participants and vulnerable subgroups: a doubly-robust approach. Lancet Planet Health.2021;5(10): e.689- e697.doi: 10.1016/S2542-5196(21)00204-7. PMID: 34627473; PMCID: PMC8525655.Bottom of Form
  11. Grandjean P, Barouki R, Bellinger DC, Casteleyn L, Chadwick LH, Cordier S, Etzel RA, Gray KA, Ha EH, Junien C, Karagas M, Kawamoto T, Paige Lawrence B, Perera FP, Prins GS, Puga A, Rosenfeld CS, Sherr DH, Sly PD, Suk W, Sun Q, Toppari J, van den Hazel P, Walker CL, Heindel JJ. Life-long implications of developmental exposure to environmental stressors: new perspectives. Endocrinology. 2016;156(10):3408-3415. 10.1210/EN.2015-1350 http://dx.doi.org/10.1210/EN.2015-1350
  12. Peng C, den Dekker M, Cardenas A, Rifas-Shiman SL, Gibson H, Agha G, Harris MH, Coull BA, Schwartz J, Litonjua AA, DeMeo DL, Hivert MF, Gilman MW, Sagiv SK, de Kluizenaar Y, Felix JF, Jaddoe VW, Oken E, Duijts L, Gold DR, Baccarelli AA. Residential proximity to major roadways at birth, DNA methylation at birth and midchildhood, and childhood cognitive test scores: project viva(Massachusetts, USA). Environ Health Perspect.2018;126(9): 097006. doi:10.1289/EHP2034 PMID: 30226399; PMCID: PMC6375460.
  13. Bejot Y, Reis J, Giroud M, Feigin V. A review of epidemiological research on stroke and dementia and exposure to air pollution. Int J Stroke. 2018; 13(7): 687-695. doi:10.1177/1747493018772800
  14. Zhang X, Chen X, Zhang X. The impact of exposure to air pollution on cognitive performance. Proc Natl Acad Sci U S.2018;115(37): 9193-9197. doi:10.1073/pnas.1809474115
  15. Zhang J, Cai Z, Ma C, Xiong J, Li H. Impacts of Outdoor Air Pollution on Human Semen Quality: A Meta-Analysis and Systematic Review. BioMed Research International. 2020; 2020:1 – 9.
  16. Dalsager L, Christensen N, Halekoh U, et al. Exposure to perfluoroalkyl substances during fetal life and hospitalization for infectious disease in childhood: a study among 1,503 children from the Odense Child Cohort. Environ Int. 2021; 149: 106395.
  17. Grandjean P, Timmermann CG, Kruse M, Nielsen F, Vinholt PJ, Boding L, Heilmann C, Mølbak K. Severity of COVID-19 at elevated exposure to perfluorinated alkylates. PLoS One. 2020; 15(12): e0244815.
  18. Chen Z, Huang BZ, Sidell MA, et al. Near-roadway air pollution associated with COVID-19 severity and mortality— multiethnic cohort study in southern California. Environ Int.2021; 157: 106862.
  19. Wu,X, Nethery, RC, Sabath, MB, Braun, D, Dominici, F. Air pollution and COVID-19 mortality in the United States: Strengths and limitations of an ecological regression analysis. Sci Adv.2020;6(45):eabd4049,1-6. DOI: 10.1126/sciadv.abd4049.
  20. Schwartz JD, Yitshak-Sade M, Zanobetti A, Di Q, Requia WJ, Dominici F, Mittleman MA. A self-controlled approach to survival analysis, with application to air pollution and mortality. Environ Int.2021;157:106861,1-7.
  21. Rosenbaum S, Byrnes M, Rothenberg S, Gunsalus R. Improving community health through hospital community benefit spending: charting a course to reform. The George Washington University: Milken Institute School of Public Health. 2016. https://hsrc.himmelfarb.gwu.edu/cgi/viewcontent.cgi?article=1825&context=sphhs_policy_facpubs Accessed Sept 30, 2023
  22. Swider SM, Berkowitz B, Valentine-Maher S, Zenk SN, Bekemeier B. Engaging communities in creating health: Leveraging community benefit. Nurs Outlook. 2017; 65(5): 657-660. doi:10.1016/j.outlook.2017.08.002
  23. Chaiyachati KH, Qi M, Werner RM. Nonprofit hospital community benefit spending and readmission rates. Popul Health Manag. 2020;23(1):85-91. doi:10.1089/pop.2019.0003
  24. Franz, B., Cronin, C.E., Yeager, VA., Burns, A., Singh, SR. Overview of the most commonly identified public health needs and strategies in a nationally representative sample of nonprofit hospitals. Med Care Res Rev. 2023;80(3):342-351. doi: 10.1177/10775587221135365
  25. Begun JW, Kahn LM, Cunningham BA, Malcolm JK, Potthoff, S. A measure of the potential impact of hospital community health activities on population health and equity. JPHMP.2018;24(5): 417-423. DOI: 10.1097/PHH.0000000000000617

You Might Also Enjoy:


Cynthia Jacelon, PhD, RN-BC, CRRN, FGSA, FAAN, is certified in gerontological and rehabilitation nursing. She is a rehabilitation clinical nurse specialist and professor, a Fellow of the American Academy of Nursing and the Gerontological Society of America. Her focus is dignity, function, self-management, and independence in older adults.

Stephen J. Cavanagh, PhD, MPA, RN, FACHE, FAAN, is the Dignity Health Dean’s Chair for Nursing Leadership at Betty Irene Moore School of Nursing at UC Davis. His leadership and research foci include health care workforce development and innovation within nursing practice.

Author Profile

Sarah K. Valentine, Cynthia Jacelon, Stephen J. Cavanagh
Sarah K. Valentine, PhD, RN, is Arthur Imperatore Community Fellow and Assistant Professor at SUNY Empire University. She is a 2023 trainee in the NIH/NIEHS Environmental Health Research Institute. Her research interests include environmental justice; environmental health; community benefit policy; nursing environmental domain; nursing philosophy, and nursing education.
Series Navigation<< Emerging Leaders in Public Health: Leaders Develop in ActionStrengthening Health Communication Education in Canada: A Call to Action >>