ABSTRACT
This study evaluated the state of environmental health in the Republic of South Africa using the strengths, weaknesses, opportunities, and threats (SWOT) analysis framework. The internal and external factor evaluations were conducted by reviewing existing literature searched using a combination of keywords and boolean functions. The weighted score for the strengths and weaknesses was 0.79 and 1.04, respectively. The external factor evaluations findings revealed that environmental health has an equal amount of threats and opportunities, however, the threats outweigh the opportunities. The total weighted score for the internal and external factor evaluations was 1.83 and 2.25, respectively, which were below the average value of 2.5. The internal-external factors matrix indicated that environmental health in the Republic of South Africa needs to be refocused and re-aligned to public health protection. Failure to address the weaknesses and threats and optimise the strengths and opportunities may further weaken the provision of environmental health services.
Introduction
Exposure to environmental stressors can lead to adverse health outcomes, some of which are irreversible (Borchers et al. Citation2006). Physical, biological, and chemical environmental stressors account for approximately 13.7 million deaths per year globally, and low to middle-income countries are the most affected (World Health Organization Citation2016a). In the African region, 2.5 million deaths per year are attributed to exposure to environmental stressors and the burden is highest among children and the elderly (World Health Organization Citation2016a). Furthermore, the highest number of deaths per capita was reported in sub-Saharan Africa (Mboera et al. Citation2014; Joubert et al. Citation2020). It was further reported that approximately 40% of the burden of diseases in sub-Saharan Africa is due to exposure to environmental stressors (Mboera et al. Citation2014). Moreover, approximately 5% of the deaths that occurred in poorly resourced countries was attributed to poor environmental conditions (Wright et al. Citation2017). However, Wright et al. (Citation2017) emphasised that the deaths could have been prevented with effective public health interventions, where EH is a central focus point of improved environmental hygiene. Therefore, there is a need to protect public health against such environmental stressors to promote sustainability and quality of life amongst populations (Prüss-Ustün et al. Citation2016).
A preventative approach, usage of available datasets, frequent biomonitoring, surveillance of environmental stressors, and research, particularly longitudinal studies are encouraged to address this public health issue (Mboera et al. Citation2014; Vardoulakis et al. Citation2016; Bornman et al. Citation2017). Studies (e.g. Musoke et al. Citation2016; Morse et al. Citation2020) have highlighted that environmental health (EH) is a key component in protecting public health. EH is concerned with all aspects of the natural and built environment that may adversely affect human health (Dhesi Citation2019; Papadopoulo et al. Citation2019). Environmental health practitioners (EHPs) are responsible for rendering environmental health services (EHS) to prevent environmental-related diseases and injuries (Whiley et al. Citation2019; Brooks et al. Citation2019). The main responsibilities of EHPs are to identify and characterize risks to human health and propose preventative measures to protect public health (Brooks et al. Citation2019). Therefore, EHPs are the first line of defence since the profession is on the prevention side rather than the curative side (Agenbag and Balfour-kaipa Citation2008; Whiley et al. Citation2019). Moreover, EHPs are responsible for various functions that impact the health and lifestyle of people (Howze et al. Citation2004; Resnick et al. Citation2009).
Food control, water quality monitoring, environmental pollution control, vector control, and solid waste management are some of the main functions of EHPs in the RSA (Department of Health Citation1991). EHPs are also responsible for the control of communicable and non-communicable diseases including the investigation of outbreaks (Department of Health Citation1991). Therefore, the multidisciplinary nature of EH requires EHPs to always be ready to protect public health with appropriate skills and knowledge (Dobson et al. Citation2019). However, the EH profession is faced with numerous unaddressed challenges such as the lack of human resources, technological resources, lack of involvement in scientific research, and workforce development (Wright et al. Citation2014; Mbola et al. Citation2019; Gerding et al. Citation2020). Despite scientific evidence on the prospects and drivers of poor environmental conditions and exposure to environmental stressors, there is a lack of implementation of interventions. The lack of implementation is attributed to insufficient research development and incapacity in the political domain or the professional space. On the other hand, there is also no political nor professional will to implement scientific evidence from academic and research institutions (Newman et al. Citation2016).
Studies (e.g. Oosthuizen and Ehrlich Citation2001; Muller et al. Citation2003; Davies and Mundalamo Citation2010; Kamunda et al. Citation2016; Morakinyo et al. Citation2016; Buthelezi et al. Citation2019) assessing environmental stressors and their impact on human health have been conducted in RSA. However, there is a dearth of scientific studies evaluating the state of EH in the country (Thomas et al. Citation2002; Mathee Citation2011; Shezi et al. Citation2019). Furthermore, there is no state of EH report that has been published in the RSA thus far (Wright et al. Citation2014). Hence, this study was conducted to evaluate the state of EH in RSA using the strengths (S), weaknesses (W), opportunities (O), and threats (T) (SWOT) analysis as shown in . To the best of our knowledge, this is the first study to evaluate the state of EH using the SWOT analysis framework. The SWOT analysis is predominantly used in the business management sector as a strategic management tool (Helms and Nixon Citation2010). However, it may also be used in other sectors including energy (Liu et al. Citation2011; Agyekum Citation2020), education (Thamrin and Pamungkas Citation2017), and healthcare services (Van Durme et al. Citation2014).
The strengths and weaknesses fall under the internal factors and can be controlled from within the organisation or profession (David et al. Citation2019; Li et al. Citation2020). The opportunities and threats fall under the external factors, which can be of harm or beneficial and are beyond the organisation’s or profession’s control (David Fred et al. Citation2019; Li et al. Citation2020). How the strengths and weaknesses are matched with the opportunities and threats to determine the success and survival of an organisation (Mbachu and Frei Citation2011). Therefore, the SWOT analysis is central to strategy formulation, implementation, and review. Given the importance of EH services in protecting public health, it is important to know such information so that improvements through research-informed decisions can be made.
Methods and materials
Published literature from multiple electronic research databases from 2000–2020 were reviewed. The literature review was done to identify trends, development, practices, and policies over 20 years. Searched databases for peer-reviewed literature included Science Direct, ProQuest, Google Scholar, Web of Science, Sabinet, SpringerLink, SAGE online, PubMed, Nature, MDPI public health, and Taylor and Francis.
The databases were searched using a combination of keywords and boolean functions that included ‘environmental health OR “public health” AND “developing countries” OR “low-middle income countries” AND environmental stressors’ OR ‘environmental hazards’ AND ‘exposure’ AND ‘research’ ‘SWOT analysis’ AND ‘South Africa’ AND ‘burden of disease’ AND ‘environmental pollution’ OR ‘contamination’. Furthermore, the snowball effect was applied when reviewing the selected journal articles. In addition, web pages, literature, and official reports from the government, World Health Organization, and the National Institute of Communicable Diseases were used. The search was done from January to December 2020 and only literature published in English was used.
The sources were then screened by reading the title and abstracts, the different sources used are presented in . The information was then used to evaluate the state of EH in RSA using the SWOT analysis. The SWOT analysis technique enables decision-makers to find solutions aimed at minimising the weaknesses and threats before they become catastrophic and optimise the opportunities and strengths to ensure sustainability (Reinsberger et al. Citation2015).
A list of the SWOTs identified during the literature review was compiled and they were extensively discussed among the authors and colleagues. The discussions were done in groups of three to eight individuals which allowed brainstorming thus preventing the dominance of individual-based perspectives which could have affected the SWOT analysis results. Based on the discussions, each author was tasked to assign weights and ratings to the identified SWOTs. The weighting was assigned based on the negative impacts of the weaknesses and threats and the positive impacts of the strengths and opportunities identified. For example, the community service backlog challenge was identified as a weakness because it further contributes to the shortage of EHPs in the country. Furthermore, the CS backlog has been a long-standing challenge and not much has been done to resolve it and was therefore assigned a higher weight and lesser response. Where there were disagreements and a huge difference between the scores and ratings of the different authors, EHPs in academia and the field were consulted telephonically at times through face-to-face interviews. In cases where the weights were different, the values were added and divided by the total number of values to get an average which was then used as a weight.
The consulted pool of individuals is employed by the Gauteng Department of Health, University of South Africa, University of Johannesburg, City of Johannesburg Metropolitan Municipality, Ekurhuleni Metropolitan Municipality, Ehlanzeni District Municipality, Gert Sibande District Municipality, and Mpumalanga Department of Health. Similar to Van Durme et al. (Citation2014), the consulted individuals were identified through formal and informal networking and were selected based on their years of experience. A total of 15 EHPs were consulted and most of the interviewed individuals had over 10 years of experience and expertise covering the SWOTs identified in this study.
The internal and external factor evaluations were used to grade the identified strengths, weaknesses, opportunities, and threats. Each identified factor was assigned a weight ranging from 0.0 to 1.0 representing the importance of the factor. A weight of 0.0 represents a factor of less impact, whereas a weight of 1.0 represents a factor with a high impact on EH and the sum of all the weights must be equal to 1. The ratings in the internal factor evaluation (IFE) represent how strong or weak are the identified internal factors, while the ratings in the external factor evaluation (EFE) describe how effectively EH responds to the opportunities and threats ().
The weighted scores were obtained using EquationEquation 1(1) (1) . EquationEquation 2(2) (2) was used to calculate the total weighted score. For example, the total weighted score for the IFE was obtained by adding the weights of the strengths with the weights of the weaknesses. In SWOT analysis, a total weighted score of 2.5 is considered as an average score. The total weighted scores from the IFE and EFE were then used to plot the internal-external factor matrix to evaluate the state of EH services in RSA.
The structure of environmental health service in RSA
EHS is the responsibility of the Minister of Health at the national government. The national EH directorate is responsible for the facilitation, implementation, and provision of EHS programmes in the country as per section nine of the National Environmental Health Policy (Department of Health). The EH directorate is also responsible for developing national policies, strategies and research and defining norms and standards that govern institutions that render EHS (Eales et al. Citation2002; Mbola et al. Citation2019). The provincial and municipal spheres of government have been allocated certain functions and responsibilities by the National Department of Health (Mbola et al. Citation2019). The municipal sphere of government includes metropolitan municipalities, district municipalities, and local municipalities (Agenbag Citation2015). RSA consists of 228 local municipalities categorised into 44 district municipalities and eight metropolitan municipalities (Shezi et al. Citation2019). presents the different EHS offered at different levels.
The conduct and practice of EHPs are regulated by the Health Professions Council of South Africa (HPCSA), an independent statutory body that regulates all the health professions in the country (Health Professions Council of South Africa Citation2019). The registration requirements for health professionals and academic institutions are stipulated by the HPCSA (Health Professions Council of South Africa Citation2019). The HPCSA also guides and informs the curriculum development procedures and ensures that learning and training institutions adhere to the fundamental competencies and training frameworks (Health Professions Council of South Africa Citation2020a). The HPCSA has a responsibility to protect the integrity of EH by ensuring that EHPs are provided with an opportunity to practice independently for what they qualified for and to secure their practising space (Health Professions Council of South Africa Citation2019). Therefore, the HPCSA must ensure that no one unlawfully practices in the EH space (Health Professions Council of South Africa Citation2019).
Results
presents the SWOTs for EH in RSA that were identified during the literature reviewand the weights allocated in consultation with EHPs in the field and academia. Based on our findings, it can be noted that EH in RSA has many weaknesses than strengths and more threats than opportunities.
presents the IFE results. The strength and weaknesses are considered internal because they are within the organisation and can be controlled through corrective measures. From , it can be noted that the strengths have a lower weighted score compared to the weaknesses. Furthermore, the total weighted score was significantly lower than the required average score of 2.5.
The EFE results are presented in . It can be noted that the opportunities had a lower weighted score relative to the threats. Also, the total weighted score was almost the required average score of 2.5.
presents the internal-external factors plot which was plotted using the total weighted scores from the IFE and EFE. It can be noted that EH in RSA was rated weak when it comes to the internal factors and medium for the external factors.
Discussions
Strengths
The strengths focus on the excellence of EH and the advantages it has in the country.
Policies and regulations
The profession has seen many pro-EH legislations been promulgated. The role of political principals has been distinguished and national stakeholder platforms that share best practices have been created (Mbola et al. Citation2019). The country’s legal system is mainly based on the constitution of the RSA (108 of Citation1996), followed by Acts, Regulations, policies, and standards. Section 24(a) of the constitution of the RSA as the mother body states that everyone has the right to an environment that is not harmful to their health or well-being (Department of Health). Therefore, EHPs are mandated to uphold section 24(a) of the constitution and protect the health, safety, and well-being of the public from environmental stressors.
Laws governing EH in the RSA include the National Health Act (61 of 2003), National Department of Health), Foodstuffs, Cosmetics and Disinfectants Act (73 of 1972), National Environmental Management: Air Quality Act (39 of 2004), National Environmental Management: Waste Act (59 of 2008), National Environmental Management Act (107 of 1998), National Water Act (36 of 1998), and Meat Safety Act (40 of 2000) (Department of Health). The National Health Act (61 of 2003) stipulates the roles and responsibilities at each sphere of government (Department of Health). Chapter 10(83) of the National Health Act stipulates that if an EHP has reasons to believe that there is the existence of a condition that (i) contravenes section 24(a) of the constitution, (ii) constitutes pollution that is detrimental to human health, (iii) is likely to or constitutes a health nuisance, the EHP must investigate such condition. To ensure integrity in the profession, the professional code of conduct and ethics that EHPs must abide by are stipulated by the Health Professions AmendmentAct (29 of 2007).
Political stability
Political instability can affect the progression of a country and how essential services such as EHS are rendered (Radu Citation2015). Studies have revealed how political instability can negatively affect the health systems, delivery of service, economy, and higher learning institutions (Shumetie and Watabaji Citation2019). RSA has had political stability since 1994 post the apartheid era, therefore, EH in RSA is secure since the country has political instability.
Knowledge sharing platforms
As part of celebrating world EH day, annual EH conferences are held in September and various governmental and non-governmental organisations such as the South African Local Government Association, labour departments, research entities, community forums, and academic institutions are invited. The conferences discuss the challenges faced by EH professionals and departments across the country and seek solutions. The conference also provides an opportunity for discussion forums, networking, and the cross-fertilisation of ideas.
Continuous professional development
In South Africa, any professional personnel register is mandated to have continuous professional development (CPD) commonly referred to as lifelong learning. Section 26 of the Health Professions Act (56 of 1974) endorses CPD to maintain and update professional competence, thus ensuring that public health is promoted through quality service delivery (Health Professions Council of South Africa Citation2017). The objective of the CPD is to help EHPs maintain and gain relevant knowledge, skills and ethical attitudes while enhancing and promoting professional integrity.
EHPs must have a minimum of 30 continuing education units per year which are valid for two years, from the 30 continuing education units, five must be for ethics, human rights, or health law (Health Professions Council of South Africa Citation2020a). Continuing education units can be obtained from two categories, the first category comprises learning activities with non-measurable outcomes such as education, training, research, and publications (Health Professions Council of South Africa Citation2020a). The second category comprises learning activities with measurable outcomes such as formal structure learning programmes (Health Professions Council of South Africa Citation2020a). For example, the main author of a peer-reviewed publication or book chapter will receive 15 continuing education units, whereas the co-authors will receive five.
Weaknesses
The weaknesses refer to the internal factors that must be avoided and responded to sufficiently for the profession to achieve its goals and objectives (Nikolaou et al. Citation2011). Numerous constraints such as funding, community backlog, lack of specialised services, relevant developmental training, buy-in from communities, and visibility of EHS professionals still affect EH in RSA.
Shortage of human resource
The WHO recommends an EHP ratio of 1:10000 people in both developed and developing countries, however, RSA adopted a national ratio of 1:15000 (Agenbag and Balfour-kaipa Citation2008; Department of Health). According to Statistics South Africa (Citation2020), the RSA mid-year population estimate is 59.62 million and as of September 2020, the HPCSA has a total of 3 565 registered EHPs on its database (Health Professions Council of South Africa Citation2020a). The division of the total population by the number of registered EHPs shows that RSA does not comply with both the World Health Organization and national EHP ratio. When using the WHO 1:10000 ratio standard, based on the RSA’s population statistics, there is a shortage of 2 397 (40.2%) EHPs, and 410 (10.3%) when using the national standard of 1:15000. Therefore, there is a shortage of EHPs in the country, a challenge that has existed for years.
The shortage of EHPs in RSA is mostly in rural areas where their services are needed the most (Agenbag and Gouws Citation2004; Reid Citation2005). For example, during the cholera outbreak that occurred in the Eastern Cape, KwaZulu-Natal and Mpumalanga Province, there was a significant shortage of EHPs, subsequently, EHPs were brought from other provinces (Eales et al. Citation2002). The shortage of human resources may force EHPs to abandon their core responsibilities which are integral to public health, which also creates a gap in the provision of EHS. Indeed, the shortage of human resources in RSA has forced EHPs to focus on reactive checklist inspections and compliance monitoring rather than a proactive preventative approach (Eales et al. Citation2002). This approach subsequently gives a perception that EH is less impactful and a relatively low priority profession that requires limited resources (Eales et al. Citation2002).
Community service backlog
Community service (CS) was introduced in 2003 as a part of training aimed at strengthening the workforce while improving service delivery (Reid et al. Citation2018). Subsequently, EHP graduates must complete a full 1-year uninterrupted compulsory CS before they can practice independently (Mbola et al. Citation2019). The purpose of community service was to accelerate career growth and development by ensuring skill transfer of graduates within the public sector. Although CS was seen as a good initiative, the systems and funding were not always in place to facilitate the placement of graduates, resulting in a backlog (Wright et al. Citation2014; Reid et al. Citation2018; Mbola et al. Citation2019). Moreover, the EH CS only accommodates indigenous university graduates, and foreign graduates who qualified in the country are excluded.
Depending on the financial situation, most EH university graduates who are not placed for CS consider furthering their studies in other fields, while some work in the private sector while waiting for CS placement (Eales et al. Citation2002; Karamchand and Kistnasamy Citation2017). Many EH university graduates who are unable to further their studies or find work elsewhere, sit and hope for CS placement while voicing out their frustrations on social media platforms. The CS backlog further creates a shortage of EHPs because EH university graduates who do not complete a full year CS are not allowed to register with the regulatory board as independent practitioners (Karamchand and Kistnasamy Citation2017). In 2018, EHPs, EHP graduates, and EH students marched to the union buildings demanding recognition and CS placement (Mbola et al. Citation2019). The march highlighted the severity and frustrations caused by the CS backlog. Nonetheless, the CS backlog continues to date with no solid solutions (Mbola et al. Citation2019).
Failure to render environmental health services
The most noticeable EHS that is poorly rendered across RSA is solid waste management (Zhou et al. Citation2016). The mismanagement of solid waste becomes a nuisance during rainy seasons due to the significant production of leachate and infestation of flies and insects (Ferronato and Torretta Citation2019). The mismanaged solid waste also provides habitat and a conducive breeding environment for rodents, which are a serious problem in RSA, particularly in the Gauteng Province (Froestad Citation2005; Jassat et al. Citation2013). The mismanagement of solid waste has also burdened public health facilities in Gauteng Province due to preventable environmental-related diseases such as plague, leptospirosis, rickettsia pox, rat-bite fever, murine typhus, Lassa fever, viral haemorrhagic fever, and Salmonellosis (Meerburg et al. Citation2009; Strand and Lundkvist Citation2019).
Lack of public awareness
EHPs are supposed to engage with populations at a community level to understand the dynamics, social and cultural norms of the communities (Morse et al. Citation2020). Engaging with communities helps build trust and it becomes easy to identify major challenges, the types of interventions needed, where they must be placed to make significant improvements in halting the spread and preventing the occurrence of diseases. However, the presence of EHPs in South African communities is limited even during EH crises, leading to a lack of public awareness (Shonhiwa et al. Citation2019). The lack of public awareness can be attributed to poor logistics and a shortage of staff. Due to the lack of public awareness, communities do not understand the nature and practice of EHPs, hence the profession subsequently lacks recognition.
The presence of EHPs in communities is important in disseminating information regarding environmental stressors (Eales et al. Citation2002), the mechanism for stressor release, transmission pathway(s), and exposure event(s). This approach can lead to an effective introduction of a preventative mechanism that focuses on the efficacy (level of protection an intervention provides), efficiency (what end-users can afford), and acceptance (what end-users prefer) (Mboera et al. Citation2014; Musoke et al. Citation2016; Masekameni et al. Citation2020). Greenhalgh et al. (Citation2014), alluded that the success of public health interventions depends on their relevance, affordability, acceptability, and consultation with the end-users.
The awareness of environmental stressors and the implementation of EH interventions can also improve the lifestyle of communities and response to environmental stressors, thus significantly decreasing their susceptibility to preventable diseases (Weis et al. Citation2005). Disseminating the right and relevant information can also help avoid unpleasant situations that unfolded during the COVID-19 outbreak where misleading information was spread (Morawska and Milton Citation2020). Furthermore, section 32 of the constitution of RSA states that everyone has the right to information held by the state or person that is required for protecting any rights (Republic of South Africa Citation1996). Therefore, EHPs are denying the public their right to information, particularly on public health-related issues. Although EHPs have the responsibility to disseminate the correct information to the public to avoid propaganda and conspiracy theories, they are invisible in the mainstream media even during EH crises (Eales et al. Citation2002; Whiley et al. Citation2019).
Lack of training
EHPs must be well trained and skilled to evolve with the changing times and EH service delivery approaches. However, the training of EHPs in RSA, particularly on the specific functions in the scope of practice guiding EHS is lacking (Selman and Green Citation2008). Subsequently, there are knowledge gaps and inconsistencies when rendering certain EHS such as the investigation of communicable disease outbreaks (Mbonane and Naicker Citation2020). Thus, EH-related issues and risk factors that contribute to the spread of disease are not properly identified and addressed during an outbreak. On the contrary, the EH scope of practice states that EHPs have a responsibility to identify environmental factors that could have contributed to disease outbreaks (Coleman Citation2016). This implies that EHPs ought to be equipped with the relevant methodologies required to assess and quantify complex and dynamic EH problems (Department of Health). It is therefore necessary to frequently review and adapt the training of EHPs to ensure that it is aligned with the current EH challenges (Health Systems Trust Citation2015).
Lack of standardisation in the EH courses among universities
Initially, the EH course was offered by two universities and five universities of technology as a three-year national diploma with an optional one year of a baccalaureus technologiae which is equivalent to an honours degree. The national diploma and baccalaureus technologiae in EH were recently replaced by a 4-year degree in EH. However, the transition to the 4-year degree was not done simultaneously in all institutions, consequently, two institutions (Mangosuthu University of Technology and the Cape Peninsula University of Technology) began offering the EH at a later stage relative to the other learning institutions. Furthermore, institutions have different names for the new 4-year degree, the Central University of Technology offers a Bachelor of Science degree in EH, the Durban University of Technology offers a bachelor of EH, whereas the remaining institutions offer a B-degree in EH.
The list of learning institutions offering the 4-year degree in EH is shown in Table S1 on the supplementary material sheet. From Table S1, it can be noted that there is no standardisation in the modules offered across the different institutions. Some institutions offer modules that are not offered in other institutions for the same EH course. For example, DUT offers biochemistry as a standalone module, at CUT it is combined with chemistry while the other institutions are not offering it all. Furthermore, some institutions offer the same modules but at different levels, and some modules are semester modules and block modules. The University of Johannesburg offers certain modules as block modules while other institutions offer them as semester modules. The lack of standardization creates an impression that certain institutions provide better and quality EH courses than others and therefore, EH graduates from such universities are more informed.
A misdirected, neglected and misunderstood profession
It is claimed that the EH profession is the most misdirected, misunderstood, overlooked, and under-recognised (Whiley et al. Citation2019). In RSA, EH seems to have moved from a preventative to a curative approach that is defying the role and function of this profession (Eales et al. Citation2002). Subsequently, responses to public health crises such as disease outbreaks are often dominated by a clinical approach (Eales et al. Citation2002; Whiley et al. Citation2019), with the impact of the EH and its preventative measures overlooked (Morawska and Milton Citation2020; Yang et al. Citation2021). A study by Rodrigues et al. (Citation2021) showed how EHPs in Portugal, the United Kingdom, the United States of America and Australia played a vital role in controlling the transmission of the coronavirus in residential and occupational settings. For example, EHPs were involved in contact tracing, risk assessment of public facilities, public spaces and workplaces, risk communication and monitored conditions in temporary shelters (Rodrigues et al. Citation2021). However, in the context of RSA, the Gauteng Department of Health recruited more nurses to combat the COVID-19 outbreak, with little consideration given to EHPs (Africa Press Office Citation2020). The invisibility of EHPs in turn diminishes the role and importance of EH, subsequently, other professions and politicians are not aware of the profession, hence it is excluded in decision-making forums (Eales et al. Citation2002; Dhesi Citation2019). This leads to EH being given less recognition even during disease outbreaks.
Lack of data science approach
Collecting environmental data is a challenge in a global context (O’ Marley et al. Citation2009; Biber Citation2013). In RSA, data collection, particularly scientific-technical datasets such as monitoring or sampling of environmental stressors are lacking (Mathee et al. Citation2010). The lack of data collection often leads to a paucity of reliable exposure data at the receptor level (Sly et al. Citation2016). Subsequently, it is challenging to spot trends of exposure to environmental stressors in communities. Data availability can enable the country to develop its exposure handbooks. For example, countries such as Canada, China, Korea, and Japan have developed their exposure handbooks through big data collection and monitoring (Filipsson et al. Citation2011; Phillips and Moya Citation2014; Jang et al. Citation2014). On the other hand, RSA continues to rely on the United States Environmental Protection Agency exposure factors that are not a true representation of the RSA population. Using such data can affect the accuracy of results, particularly when conducting a human health risk assessment (Masekameni et al. Citation2019).
It has been widely proven that EH challenges can be controlled using research-based decisions (Briggs Citation2000; Biber Citation2013; Couch et al. Citation2016). For example, EH research can help understand challenges such as climate change, exposure to nanoparticles and persistent chemical pollutants (Couch et al. Citation2016; Shezi et al. Citation2019). However, sufficient data must be collected to understand the exposure pathway (Briggs Citation2000). The source(s), nature of the stressor, transport media, and receptors must be known and it must also be determined whether there is a possibility of the stressor changing from one transport media to another (Bonnefoi et al. Citation2010).
Information on the receptors is important as it gives an insight into the variability within the community and susceptible groups. For example, in a community that relies on river water for drinking, pregnant women, the elderly, and children under five years, and the sick will be at the highest risk of developing adverse health effects if the water is contaminated (Joubert et al. Citation2020). The ingestion route is one of many exposure pathways, exposure can also occur through ingestion of vegetables watered with the contaminated water and the dermal route when bathing with the contaminated water (Mathee Citation2011; Genthe et al. Citation2018). Moreover, there is evidence (e.g. Khan et al. Citation2008; Amin et al. Citation2013; Mehmood et al. Citation2019) that edible plants can be contaminated with heavy metals that are uptaken through the roots, soil, or during irrigation with contaminated water (Genthe et al. Citation2018).
With the availability of data, simulations and models can be done to predict future exposure using probabilistic risk assessment approaches (Bonnefoi et al. Citation2010). Such information can also be used to select effective interventions and whether they should be placed at the source, along the pathway, or the receptor level (Weis et al. Citation2005). Therefore, data collection and understanding of the exposure pathway are fundamental in protecting the public against environmental stressors (Lioy Citation2010).
Lack of research and development
EHPs have highlighted the necessity of being actively involved in research to make their work evidence-based (Couch et al. Citation2016). However, little has been done to achieve this goal, even though the profession provides an opportunity for research and development (Couch et al. Citation2016). Subsequently, there is a lack of data that impedes EH research and the implementation of evidence-based interventions (Department of Health). The lack of research is also caused by insufficient funding needed to conduct large studies (Briggs Citation2000).
Exposure to chemical stressors through the environmental media has been identified as a major problem, and most of these chemical stressors are endocrine-disrupting chemicals (World Health Organization Citation2016b; Bornman et al. Citation2017). However, Nweke et al. (Citation2009) reported that there is limited research to address the human health impacts of these stressors. Nonetheless, a bibliometric study by Wright et al. (Citation2017) evaluating an 18-year trend of EH research in the RSA concluded that there is a promising steady growth in research output. However, the amount of EH research output is not satisfactory, particularly when compared to other European countries (Wright et al. Citation2017).
Lack of specialisation
EH offers an opportunity for specialisation due to its holistic approach and multidisciplinary nature that allows EHPs to collaborate with other professionals (Morse et al. Citation2020). For example, during an outbreak or pandemic, EHPs work closely with epidemiologists during the case investigation. Despite the specialisation opportunity that EH offers, there is a lack of specialisation career paths for EHPs in the RSA public health sector. Most EHPs work for many years after obtaining their national diploma and never advance their studies to grow and develop professionally. Anecdotal information suggests that most EHPs when they further their studies, it is outside of the scope of EH. For example, most EHPs have a postgraduate degree in business administration and environmental management. Growth and development within the EH profession can help improve the profession in the country. The global health dynamics are changing daily and there is a need to ensure that EHPs can handle EH problems effectively and efficiently (Day Citation2016).
Opportunities
The opportunities refer to the external benefits that EHPs can optimise to improve the delivery of EHSs and grow the profession (Nikolaou et al. Citation2011). Opportunities have positive effects on the profession and can be optimised through the profession’s strengths (Mbachu and Frei Citation2011).
Access to higher education
Access to higher education in the country has improved and the number of students enrolled at higher institutions is increasing annually (Statistics South Africa Citation2019). Based on data from 2002, 10 learning institutions were graduating an average of 350 EH students per year and the numbers have likely increased in recent years (Eales et al. Citation2002). The EH course in RSA is offered at two universities (University of Johannesburg and Nelson Mandela University) and five universities of technology (Tshwane University of Technology, Durban University of Technology, Mangosuthu University of Technology and Cape Peninsula University of Technology and Central University of Technology) (Health Professions Council of South Africa Citation2020b). The EH course comprises a blend of theory and practical work whereby students are required to complete certain hours of work-integrated learning to gain experience. For example, during recess, students work with qualified EHPs and also visit the abattoir, hospitals and clinics and they must produce a portfolio of evidence for activities done. The course was initially offered as a 3-year national diploma with one optional year of a baccalaureus technologiae.
Given the rapid changes in environmental stressors, well-trained, competitive, and educated EHS graduates are needed to protect public health effectively and efficiently (Day Citation2016; Ahonen and Lacey Citation2017; Arshad et al. Citation2018). Therefore, the EH course was changed to a 4-year degree to better equip students with the relevant skills, knowledge, and expertise required to evaluate the risks posed by environmental stressors (Health Systems Trust Citation2015).
Research and development
Research has been considered the centre stone of capacity building and strengthening databases (Couch et al. Citation2016). As such, the importance of research in EH cannot be overlooked. Moreover, Chapter 9 of the National Health Act (61 of 2003), states that the minister must establish a national health research committee council. The committee must develop the application and implementation of an integrated national strategy for health research, coordinate the research activities of public health authorities and identify health research priorities (Department of Health). The health research priorities must address (i) the burden of diseases, (ii) the cost-effectiveness of interventions aimed at reducing the burden of diseases, (iii) availability of human and institutional resources for the implementation of an intervention at the level close to the affected communities, (iv) health needs of vulnerable groups such as woman, children, people with disabilities and the elderly and (v) health needs of communities (Department of Health).
Through research, knowledge gaps can be identified and closed. This is important given that the dynamics of EH are changing from time to time, thus providing an opportunity to study and better understand the problems (Department of Health). The research will also open discussion platforms and provide an opportunity for collaboration with other professionals (Couch et al. Citation2016). EH research will further help make informed decisions and implement effective evidence-based interventions and ensure capacity building within the profession (Dhesi and Stewart Citation2015; Couch et al. Citation2016)
Specialisation
The nine functions of EH and the range of specialism allow EHPs to develop interdisciplinary skills (Morse et al. Citation2020). The interdisciplinary skills of EHPs are regarded as a significant strength that can be used to collaborate and enhance specialisation which will help make well-informed decisions (Couch et al. Citation2016). Mbonane and Naicker (Citation2020) found that the majority (80.3%) of EHPs believed that rendering all functions of EHS is not productive and impairs their performance. Furthermore, 62.3% of EHPs highlighted the need for specialisation to address current EH challenges in poorly-resourced countries (Mbonane and Naicker Citation2020).
Threats
The threats refer to the external barriers that can inhibit EH to reach its goals and objectives and must be overcome (Nikolaou et al. Citation2011). The threats have negative effects on the profession because they impact the profession’s weaknesses (Mbachu and Frei Citation2011).
Risk of outbreaks
The threats related to EH in RSA are a consequence of not addressing the weaknesses within the profession, which often leads to loss of life and disability. The listeriosis outbreak that occurred between January 2017 and March 2018 is a good example. The outbreak resulted in 1 200 confirmed cases and 998 deaths and was recorded as the largest outbreak ever recorded globally (National Institute of Communicable Diseases Citation2018; World Health Organization Citation2018; Boatemaa et al. Citation2019). Shockingly, the involvement of EHPs during the listeriosis outbreak was limited (Shonhiwa et al. Citation2019).
Similarly, amid the ongoing COVID-19 pandemic there is still a limited involvement of EHPs, despite that the pandemic was officially declared a national disaster. Several studies (e.g. Eldridge and Tenkate Citation2006; Gamboa-Maldonado et al. Citation2012; Fafard Citation2015; Lichtveld et al. Citation2020) have highlighted the importance of EHPs in disaster management. Importantly, EHPs are responsible for planning, hazard identification, human health risk assessment, communication, and ensuring uninterrupted EHS to reduce the potential health effects of the disaster. During the COVID-19 pandemic, EHPs were supposed to conduct contact tracing to enforce the public health regulations as per the National Disaster Act (57 of 2002). EHPs were also responsible for the identification of environmental risk factors and implement interventions to prevent the spread of the coronavirus (Morse et al. Citation2020). However, according to anecdote evidence, EHPs were involved with patient care whereby they were conducting contact tracing to check if patients were taking their treatment (National Department of Health Citation2020).
Lack of funding
There is a global trend of insufficiently funding for public health even though it is on the preventative side (Moran Citation2016; Sen-Crowe et al. Citation2020). In RSA, insufficient funds are allocated to EHS yearly, subsequently, it becomes difficult to allocate CS placement for EH graduates and recruit employees to strengthen the workforce (Department of Health). Due to insufficient funding, there are ‘frozen posts’ that cannot be advertised nor filed because there is no money, the situation has created a significant unemployment gap that further adds to the shortage of human resources (Eales et al. Citation2002). The insufficient funding also leads to a lack of bursaries and scholarships for students who wish to do EH and for qualified EHPs who wish to further their studies in the field (Mbola et al. Citation2019).
Bursaries and scholarships are a significant source of financial support, particularly for low-income students (Callender Citation2010). It has been proven that students are likely to select a course where there is financial support either in a form of bursaries or scholarships (Kaye Citation2020). Therefore, the lack of bursaries can affect the number of enrolments and EH graduates produced. A high enrollment for the EH course will ensure that the profession does not have a shortage of workforce, provided EHP graduates are placed for CS. Couch et al. (Citation2016), highlighted that EH will probably remain a distinctly vulnerable profession until EHPs illustrate the importance and value of their work to decision-makers and funders.
Illegal practising and impersonation of EHPs
To practice as an EHP in the RSA, an individual must register with the HPCSA and pay annual fees to renew the registration. Failure to pay the annual fee will lead to suspension from the register, therefore, an individual must pay an annual fee to remain in the register and practice. Nonetheless, some EHPs are not in good standing with the HPCSA and yet they are practising, meaning that the individuals are practising illegally. Secondly, there is a growing trend of EHP impersonators that is witnessed in the metropolitan municipalities of RSA (Kahla Citation2018; Writer Citation2018; Carr Citation2020). The impersonators produce falsified certification to consumers and if any misconduct is found on the consumers’ side, bribery is demanded to avoid legal measures (Naidoo Citation2019; Jordaan Citation2020). The impersonators target areas that seem to be neglected by the official EHPs and take advantage of their absence. Although the HPCSA states that unregistered and or unqualified personnel practising as EHPs are committing a criminal offence (Health Professions Council of South Africa Citation2019), little is being done to solve this problem. Meanwhile, this trend is destroying the image of the profession in the country. Subsequently, people are losing hope in the profession.
Internal and external factor evaluation matrix analysis
To better understand how the factors identified during the SWOT analysis () affect the state of EH in RSA, the IFE, and EFE were conducted. The major internal and external factors are listed and rated in , respectively. From , it can be noted that the strengths have a lower weighted score relative to the weaknesses. Furthermore, the total weighted score is significantly lower than the required average score of 2.5. The low total weighted score in the IFE is an indication that the profession is weak internally and does not respond effectively to the strengths and weaknesses. Therefore, the profession might be weakened thus not adequately serving its purpose of protecting public health through.
presents the EFE, and it can be noted that the opportunities had a lower weighted score relative to the threats. However, the total weighted score was near the required average of 2.5. The low total weighted score in the EFE is an indication that the profession’s strategies are not designed to effectively optimise the opportunities and fight against the threats. presents the internal-external factor matrix results of EH in RSA. The IFE and EFE matrix analysis enable policy and decision-makers to focus on critical factors that might have catastrophic results if not addressed sufficiently. Based on the internal-external factor matrix results, EH in RSA must harvest and divest. This implies that there is a need to restructure and develop EH in RSA so that it can meet its objectives of protecting public health. Failure to harvest and divest means that the profession might be at the risk of being dysfunctional.
Recommendations
Based on the SWOT analysis and internal-external matrix on the state of EH in RSA, the following recommendations are suggested to policy and decision-makers. The recommendations are aimed at improving the state of EH in the country given its value and importance to public health.
Efforts must be made to address the CS backlog, it must be ensured that at least 80%–90% of the EH graduates are placed for CS annually to strengthen the EH workforce. Post CS, it must be ensured that the graduates are either retained or given an employment opportunity. EHPs need to be in driving seat and be proactive when it comes to controlling environmental stressors and rendering EHS in the country. A risk-based or preventative approach is recommended to address all the EH issues in the country. EHPs should take the initiative and start being visible on public platforms, particularly during EH crises. EHPs must know that it is their responsibility to ensure that the profession is not overlooked nor misdirected, and that can be achieved by their visibility. Their visibility and adequately doing their job will also close the opportunity for EHP impersonators that are destroying the profession’s integrity.
There must be a solid relationship between higher institutions offering the EH course, municipalities, and regulatory bodies. Municipalities and regulatory bodies must inform universities of the EH challenges they encounter in the field. Learning institutions offering the EH course must prepare the upcoming generation of EHPs by equipping them with the necessary skills required to better understand and solve the identified EH challenges. Furthermore, EHPs must be well trained and skilled and evolve with the times and dynamics of EH. Therefore, it is recommended that the training related to EH must be conducted by higher learning institutions offering the EH course must and inform them of the new trend in environmental exposures. Moreover, the training and content thereof must be informed and directed by emerging EH challenges experienced in the field.
The EH course in the country must be standardised across the different institutions to achieve harmony, despite the different names given to the EH course. Ultimately, the fieldwork gives cognisant to EH despite the nature of the qualification and the aim is to produce quality EHPs that will serve the country and protect public health
In other countries, big studies (e.g. Turpin et al. Citation2007; Hoek et al. Citation2008; Borrego et al. Citation2016) aiming to understand exposure to environmental contaminants have been conducted and were a success, however, the kind of studies requires financial resources. Therefore, to ensure research and development in the field of EH, there must be enough funding allocated to research and development. Students can be incorporated into research projects as part of their masters of honours and doctorate courses. Over time, the students will develop a passion for the research work they are involved in and there are likely to specialise in that field.
The ongoing COVID-19 outbreak is not the first nor the last, therefore, it is important to learn from it and take steps to improve preparedness (Anderson et al. Citation2020). Early detection and warning systems are fundamental in protecting public health, EHPs must determine how the COVID-19 situation in RSA could have been avoided or minimised and how such situations can be prevented in the future. Given that diseases can rapidly spread globally and transition into lethal pandemics such as the COVID-19, emergency preparedness and response, surveillance, and control of communicable diseases must be strengthened to protect public health (Musoke et al. Citation2016). Insufficient funding was identified as a root cause of the challenges faced in the country. Therefore, the annual budget allocated to EH must be increased to address the lack of human resources, data collection and research, bursaries and scholarships, and CS backlog. The HPCSA must also start playing its role as a regulatory body that is responsible for protecting the practising space of EHPs and the integrity of EH. The HPCSA must also ensure standardisation in the offering of the EH course across all institutions.
Conclusions
For the first time in the context of RSA, the state of EH was holistically evaluated using the SWOT analysis framework. The study also highlighted the importance of EH in protecting public health and ensuring sustainability. Findings from this study can be used as building blocks to strategies and build a future EH profession that is centred on disease prevention by controlling environmental stressors. The total weighted score of 1.83 for the IFE indicated that EH is not responding positively to the strengths and weaknesses while the total weighted score of EFE indicated that EH is not effectively responding to opportunities and threats. The internal-external matrix analysis indicated that EH in RSA needs urgent restructuring if it is to meet the changing and dynamic needs of communities and achieve its objectives of protecting public health. To ensure that EH remains relevant in RSA, concerted efforts must be made to address the weaknesses, opportunities, and threats highlighted in this paper while improving on the strengths. Failure to address the weaknesses, opportunities, and threats and restructure and align the profession with the current EH challenges in RSA might lead to more catastrophic public health events.
Supplemental Material
Download MS Word (31.3 KB)Acknowledgments
The authors would like to thank Yonda “YoYo” Nokhwethu, Boipelo “BloBlo” Bhuda, Nkosinathi Moses Lukhele, Mosima Success “Graduate” Letsoalo, Siyanda Nkosi, Nomsa Duduzile Lina Thabethe, Oscar Rikhotso, Justice Malegodi Thobejane and Dr Phoka Caiphus Rathebe for their valuable insights. We also appreciate the help China Seremi Mooa for his valuable assistance with data presentation and visualisation.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Supplementary materials
Supplemental data for this article can be accessed here.
Additional information
Funding
References
- Africa Press Office. 2020. Coronavirus – South Africa: Gauteng Health Department embarks on a massive recruitment drive to fight against COVID-19 [Internet]. [accessed 2020 Mar 30]. https://www.cnbcafrica.com/apo/2020/03/27/coronavirus-south-africa-gauteng-health-department-embarks-on-a-massive-recruitment-drive-to-fight-against-covid-19/
- Agenbag M 2015. Recognising the role of environmental health in the public health fraternity: a South African perspective. 14th World Congr Public Heal – Kolkata – India – 11 – 15 Febr 2015 [Internet], Kolkata.[accessed 2020 Mar 9]. http://digitalknowledge.cput.ac.za/xmlui/handle/11189/4490
- Agenbag M, Balfour-kaipa T. 2008. Developments in environmental health. South African Heal Rev. 2008:149–160.[accessed 2020 Mar 9]. http://www.hst.org.za/uploads/files/chap10_08.pdf.
- Agenbag M, Gouws M 2004. Redirecting the role of environmental health in South Africa. In: Int Fed Environ Heal 8th World Conf Durban ICC [Internet]. Durban.[accessed 2020 Mar 9]. http://digitalknowledge.cput.ac.za/xmlui/handle/11189/2500
- Agyekum EB. 2020. Energy poverty in energy rich Ghana: a SWOT analytical approach for the development of Ghana’s renewable energy. Sustain Energy Technol Assessments. 40:100760. 40. doi:10.1016/j.seta.2020.100760.
- Ahonen EQ, Lacey SE. 2017. Undergraduate environmental public health education: developmental evaluation to reframe a degree in a new school. New Solut. 27(1):107–123. doi:10.1177/1048291117697110.
- Amin NU, Hussain A, Alamzeb S, Begum S. 2013. Accumulation of heavy metals in edible parts of vegetables irrigated with waste water and their daily intake to adults and children, District Mardan, Pakistan. Food Chem. 136(3–4):1515–1523. Internet. doi:10.1016/j.foodchem.2012.09.058.
- Anderson M, Mckee M, Mossialos E. 2020. Covid-19 exposes weaknesses in European response to outbreaks. BMJ. [accessed 2020 Mar 24]. m1075. https://euobserver.com/social/147659 Internet.
- Arshad K, Lean QY, Ming LC, Mahalingam SR, Tiong CS, Abdullah AH, Shafie FA. 2018. A survey on topics rating for the undergraduate and diploma in environmental health. SAGE Open. [accessed 2020 Mar 24]. 8(4):215824401881104. https://doi.org/10.1177/2158244018811049 Internet.
- Biber E. 2013. The challenge of collecting and using environmental monitoring data. Ecol Soc. 18(4):art68. [accessed 2020 Sep 24]. Internet.http://www.ecologyandsociety.org/vol18/iss4/art68/.
- Boatemaa S, Barney M, Drimie S, Harper J, Korsten L, Pereira L. 2019. Awakening from the listeriosis crisis: food safety challenges, practices and governance in the food retail sector in South Africa. Food Control. [accessed 2020 Aug 25]. 104: 333–342. doi:10.1016/j.foodcont.2019.05.009. Internet.
- Bonnefoi MS, Belanger SE, Devlin DJ, Doerrer NG, Embry MR, Fukushima S, Harpur ES, Hines RN, Holsapple MP, Kim JH, et al. 2010. Human and environmental health challenges for the next decade. Crit Rev Toxicol. [Internet]. [accessed 2020 Sep 7] 40(10):893–911. https://www.tandfonline.com/action/journalInformation?journalCode=itxc20
- Borchers AT, Chang C, Keen CL, Gershwin ME. 2006. Airborne environmental injuries and human health. Clin Rev Allergy Immunol. 31(1):1–101. doi:10.1385/CRIAI:31:1:1.
- Bornman MS, Aneck-Hahn NH, de Jager C, Wagenaar GM, Bouwman H, Barnhoorn IEJ, Patrick SM, Vandenberg LN, Kortenkamp A, Blumberg B, et al. 2017. Endocrine disruptors and health effects in Africa: a call for action. Environ Health Perspect. [Internet]. [accessed 2020 Aug 22]. 125(8):085005. doi: 10.1289/EHP1774.
- Borrego C, Costa AM, Ginja J, Amorim M, Coutinho M, Karatzas K, Sioumis T, Katsifarakis N, Konstantinidis K, De Vito S, et al. 2016. Assessment of air quality microsensors versus reference methods: The EuNetAir joint exercise. Atmos Environ. [accessed 2019 Apr 4]. 147:246–263. doi:10.1016/j.atmosenv.2016.09.0501352-2310/. [Internet].
- Briggs D. 2000. Environmental health hazard mapping for Africa. Geneva. [accessed 2020 Sep 27].
- Brooks BW, Gerding JA, Landeen E, Bradley E, Callahan T, Cushing S, Hailu F, Hall N, Hatch T, Jurries S, et al. 2019. Environmental health practice challenges and research needs for U.S. Health Departments. Environ Health Perspect. [Internet]. [accessed 2020 Aug 21]. 127(12):125001. doi:10.1289/EHP5161.
- Buthelezi SA, Kapwata T, Wernecke B, Webster C, Mathee A, Wright CY. 2019. Household fuel use for heating and cooking and respiratory health in a low-income, South African coastal community. Int J Environ Res Public Health. [Internet]. [accessed 2020 Jun 25]. 16(4):550. www.mdpi.com/journal/ijerph
- Callender C. 2010. Bursaries and institutional aid in higher education in England: do they safeguard and promote fair access? Oxford Rev Educ. [Internet].[accessed 2020 Sep 12]. 36(1):45–62 https://www.tandfonline.com/action/journalInformation?journalCode=core20.
- Carr J. 2020. Robbers disguised as health inspectors steal £10,000 from South African supermarket. MailOnline [Internet]. [ accessed 2020 Aug 22]. https://www.dailymail.co.uk/news/article-8391679/Robbers-disguised-health-inspectors-steal-10-000-South-African-supermarket.html
- Coleman EW. 2016. Equipping environmental health workers with environmental assessment tools. J Environ Health. Internet.[accessed 2020 Sep 5]. 78(1):36–38. http://www.ncbi.nlm.nih.gov/pubmed/4620656%0Ahttp://www.ncbi.nlm.nih.gov/pubmed/26427267%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC4620656
- Couch R, Barratt C, Dhesi S, Stewart J, Page A. 2016. Environmental Health. In: Clay’s Handb Environ Heal [Internet]. 21st. ed. Milton Park (Abingdon, Oxon; New York, NY): Routledge. [accessed 2020 Mar 24]. 102–127. https://www.taylorfrancis.com/books/9781317382911/chapters/10.4324/9781315675688-11
- David FR, Creek SA, David Forest R. 2019. What is the key to effective SWOT analysis, including AQCD factors. SAM Adv Manag J. [Internet]. [accessed 2020 Sep 16]. 84(1):25–35. http://search.ebscohost.com/login.aspx?direct=true&db=buh&AN=142057282&lang=de&site=eds-live&scope=site
- Davies TC, Mundalamo HR. 2010. Environmental health impacts of dispersed mineralisation in South Africa. J African Earth Sci. [Internet]. 584: 652–666. http://cnx.org/content/m22302/latest/graphics1.png [accessed 2021 May 25].
- Day C. 2016. Environmental health – a changing practice. In: Clay’s Handb Environ Heal [Internet]. 21st ed. Milton Park (Abingdon, Oxon; New York, NY): Routledge. [accessed 2020 Mar 24] 82–111. https://www.taylorfrancis.com/books/9781317382911/chapters/10.4324/9781315675688-11
- Department of Environmental Affairs and Tourism. 1998. National Environmental Act 107 of 1998. Republic of South Africa: South African Government; [accessed 2019 Aug 12]. https://www.environment.co.za/documents/legislation/NEMA-National-Environmental-Management-Act-107-1998-G-19519.pdf
- Department of Environmental Affairs and Tourism. 2005. National Environment Management: Air Quality Act 39 of 2004 [Internet]. Republic of South Africa: South African Government; [accessed 2021 Oct 19]. https://www.gov.za/sites/default/files/gcis_document/201409/a39-04.pdf
- Department of Environmental Affairs and Tourism. 2009. National Environmental Management: Waste Act 59 of 2008 [Internet]. Cape Town, Republic of South Africa: South African Government; [accessed 2019 Mar 1]. https://www.environment.gov.za/sites/default/files/legislations/nema_amendment_act59.pdf
- Department of Health. 1991. Health Professions Act 56 of 1974: Regulations defining the scope of the profession of environmental health practitioners. Republic of South Africa: South African Government. http://www.hpcsa.co.za/Uploads/editor/UserFiles/downloads/legislations/acts/health_professions_ct_56_1974.pdf
- Department of Health. 2000. Meat Safety Act (40 of 2000) [Internet]. Republic of South Africa: South African Government; [accessed 2021 Oct 19]. https://www.gov.za/sites/default/files/gcis_document/201409/a40-000.pdf
- Department of Health. 2008. Health Professions Amendment Act 29 of 2007 [Internet]. Republic of South Africa: South African Government; [accessed 2021 Oct 20]. https://www.gov.za/sites/default/files/gcis_document/201409/a29-07.pdf
- Department of Health. 2004. National Health Act 61 of 2003 [Internet]. Republic of South Africa: South African Government; [accessed 2021 Feb 7]. https://www.gov.za/documents/national-health-act
- Department of Health. 2010. Foodstuffs, Cosmetics and Disinfectants Act (54 of 1972): Regulations: Labeling and advertising of foodstuffs [Internet]. Republic of South Africa: South African Government; [accessed 2021 Oct 19]. https://www.gov.za/sites/default/files/gcis_document/201409/32975146.pdf
- Department of Health. 2013. National Environmental Health Policy [Internet]. Pretoria, Republic of South Africa: South African Government; [accessed 2020 Mar 24]. https://www.gpwonline.co.za
- Department of Water Affairs. 1998. National Water Act (36 of 1998) [Internet]. Republic of South Africa: South African Government; [accessed 2021 Oct 19]. https://www.gov.za/sites/default/files/gcis_document/201409/a36-98.pdf
- Dhesi S, Stewart J. 2015. The developing role of evidence-based environmental health. SAGE Open. 5(4):215824401561171. Internet. [accessed 2020 May 25]. http://journals.sagepub.com/doi/10.1177/2158244015611711.
- Dhesi S. 2019. Tackling health inequalities : reinventing the role of environmental health. Abingdon: Routledge.
- Dhesi S, Stewart J. 2015. The developing role of evidence-based environmental health. SAGE Open. 5(4):215824401561171. Internet. [accessed 2020 May 25]. http://journals.sagepub.com/doi/10.1177/2158244015611711.
- Dobson J, Shugart JM, Bante KL. 2019. Work, school, and training in the environmental health field: a lifelong relationship. J Environ Health. 82(5):28–31.
- Eales K, Dau S, Phakati N. 2002. Environmental health: framework for transformation. South African Heal Rev:101–116. Durban: Health Systems Trust. [accessed 2020 Sep 1].
- Eldridge D, Tenkate TD. 2006. The role of environmental health in disaster management : an overview and review of barriers and facilitators for action the role of environmental health in disaster management: an overview and review of barriers and facilitators for action. Rev Environ Health. [Internet]. [accessed 2021 May 25. 214: 281–294. http://eprints.qut.edu.au/
- Fafard P. 2015. Beyond the usual suspects: using political science to enhance public health policy making. J Epidemiol Community Health. 69(11):1129–1132. doi:10.1136/jech-2014-204608.
- Ferronato N, Torretta V. 2019. Waste mismanagement in developing countries: a review of global issues. Int J Environ Res Public Health. [Internet]. [accessed 2020 Sep 16]. 16(6):1060. https://www.mdpi.com/1660-4601/16/6/1060.
- Filipsson M, Oberg T, Bergbäck B. 2011. Variability and uncertainty in Swedish exposure factors for use in quantitative exposure assessments. Risk Anal. [Internet]. [accessed 2019 Jul 23] 31(1):108–119. https://0-onlinelibrary-wiley-com.innopac.wits.ac.za/doi/pdf/10.1111/j.1539-6924.2010.01464.x
- Froestad J. 2005. Environmental health problems in Hout Bay: the challenge of generalising trust in South Africa. J South Afr Stud. [Internet]. [accessed 2020 Aug 31]. 31(2):333–356. https://www.tandfonline.com/action/journalInformation?journalCode=cjss20.
- Gamboa-Maldonado T, Marshak HH, Sinclair R, Montgomery S, Dyjack DT. 2012. Building capacity for community disaster preparedness: a call for collaboration between public environmental health and emergency preparedness and response programs. J Environ Health. 75(2):24–29.
- Genthe B, Kapwata T, Le W, Chamier J, Wright CY. 2018. The reach of human health risks associated with metals/metalloids in water and vegetables along a contaminated river catchment : South Africa and Mozambique. Chemosphere. Internet, 199:1–9. doi:10.1016/j.chemosphere.2018.01.160.
- Gerding JA, Brooks BW, Landeen E, Whitehead S, Kelly KR, Allen A, Banaszynski D, Dorshorst M, Drager L, Eshenaur T, et al. 2020. Identifying needs for advancing the profession and workforce in environmental health. Am J Public Health. 110(3):288–294. doi:10.2105/AJPH.2019.305441
- Greenhalgh T, Howick J, Maskrey N. 2014. Evidence based medicine: a movement in crisis? BMJ. [Internet]. [accessed 2020 May 25]. 348(jun13):g3725. www.lindalliance.org.
- Health Professions Council of South Africa. 2017. Continuing professional development guidelines for the health practitioners. Pretoria.
- Health Professions Council of South Africa. 2019. Health Professions Council of South Africa Environmental Health Practitioners NEWS newsletter for the professional board for environmental health practitioners. Pretoria.
- Health Professions Council of South Africa. 2020a. Statistics [Internet]. [ accessed 2020 Sep 13]. https://www.hpcsa.co.za/?contentId=412&actionName=Publications
- Health Professions Council of South Africa. 2020b. List of institutions presenting environmental health programmes. Pretoria.
- Health Systems Trust. 2015. Environmental Health in South Africa [Internet]. [Durban]; [ accessed 2020 Mar 24]. www.hst.org.za/publications/south-
- Helms MM, Nixon J. 2010. Exploring SWOT analysis – where are we now?: a review of academic research from the last decade. J Strateg Manag. [Internet]. [accessed 2020 Aug 9]. 33: 215–251. www.emeraldinsight.com/1755-425X.htm
- Hoek G, Kos G, Harrison R, de Hartog J, Meliefste K, Ten Brink H, Katsouyanni K, Karakatsani A, Lianou M, Kotronarou A, et al. 2008. Indoor-outdoor relationships of particle number and mass in four European cities. Atmos Environ. 42(1):156–169. doi:10.1016/j.atmosenv.2007.09.026
- Howze EH, Baldwin GT, Kegler MC. 2004. Environmental health promotion: bridging traditional environmental health and health promotion. Heal Educ Behav. [Internet]. [accessed 2020 Mar 24]. 314: 429–440. http://journals.sagepub.com/doi/10.1177/1090198104265591
- Jang J-Y, Jo S-N, Kim S-Y, Myung H-N. 2014. Overview of the development of the Korean exposure factors handbook. J Prev Med Public Heal. [Internet]. 47(1):1–6. [accessed 2021 Mar 11]. http://dx.doi.org/10.3961/jpmph.2014.47.1.1
- Jassat W, Naicker N, Naidoo S, Mathee A. 2013. Rodent control in urban communities in Johannesburg, South Africa: from research to action. Int J Environ Health Res. [Internet.] 23(6):474–483. [accessed 2020 Sep 17]. https://www.tandfonline.com/action/journalInformation?journalCode=cije20.
- Jordaan N. 2020. “Health inspector” bust trying to scam foreign shop owners in Western Cape. TimesLive [Internet]. [ accessed 2020 Aug 22]. https://www.timeslive.co.za/news/south-africa/2020-06-10-health-inspector-bust-trying-to-scam-foreign-shop-owners-in-western-cape/
- Joubert BR, Mantooth SN, McAllister KA. 2020. Environmental health research in Africa: important progress and promising opportunities. Front Genet. [Internet]. [accessed 2020 Jul 5]. 10:1166. www.frontiersin.org
- Kahla C 2018. Ekurhuleni mayor warns residents about fake city inspectors. The South African [Internet]. [ accessed 2020 Aug 22]. https://www.thesouthafrican.com/news/ekurhuleni-mayor-warns-residents-about-fake-city-inspectors/
- Kamunda C, Mathuthu M, Madhuku M. 2016. Health risk assessment of heavy metals in soils from witwatersrand gold mining basin, South Africa. Int J Environ Res Public Health. 13:7. doi:10.3390/ijerph13070663.
- Karamchand A, Kistnasamy EJ. 2017. Experiences of community service environmental health practitioners. SA J Hum Resour Manag. [Internet.]. 1(2):1–8. [accessed 2020 Mar 28]. https://sajhrm.co.za/index.php/sajhrm/article/view/867.
- Kaye N. 2020. Evaluating the role of bursaries in widening participation in higher education: a review of the literature and evidence. Educ Rev. [Internet]. 1–23. doi:10.1080/00131911.2020.1787954.
- Khan S, Cao Q, Zheng YM, Huang YZ, Zhu YG. 2008. Health risks of heavy metals in contaminated soils and food crops irrigated with wastewater in Beijing, China. Environ Pollut. [Internet]. [accessed 2020 Oct 1]. 152(3):686–692. www.elsevier.com/locate/envpol
- Li C, Negnevitsky M, Wang X. 2020. Prospective assessment of methanol vehicles in China using FANP-SWOT analysis. Transp Policy. [Internet]. 96:60–75. [accessed 2020 Aug 20]. doi:10.1016/j.tranpol.2020.06.010.
- Lichtveld M, Covert H, El-Dahr J, Grimsley LF, Cohn R, Watson CH, Thornton E, Kennedy S. 2020. A community-based participatory research approach to hurricane Katrina: when disasters, environmental health threats, and disparities collide. Am J Public Health. [accessed 2021 May 25]. 110(10): 1485–1489. http://www.ajph.org Internet.
- Lioy P. 2010. Exposure science: a view of the past and milestones for the future. Environ Health Perspect. [Internet]. [accessed 2019 Feb 19]. 1188: 1081–1090. http://content.ebscohost.com/ContentServer.asp?EbscoContent=dGJyMNLr40Sep7c4xNvgOLCmr1GeprZSsKq4Sq6WxWXS&ContentCustomer=dGJyMPGssVGup7VRuePfgeyx9Yvf5ucA&T=P&P=AN&S=R&D=hxh&K=57125423
- Liu TT, McConkey BG, Ma ZY, Liu ZG, Li X, Cheng LL. 2011. Strengths, weaknessness, opportunities and threats analysis of bioenergy production on marginal land. Energy Procedia. [Internet]. 5: 2378–2386. place unknown]; [accessed 2020 Aug 9. www.sciencedirect.com
- Masekameni MD, Moolla R, Gulumian M, Brouwer D. 2019. Risk assessment of benzene, toluene, ethyl benzene, and xylene concentrations from the combustion of coal in a controlled laboratory environment. Int J Environ Res Public Health. [Internet]. 16(1). [accessed 2020 May 5]. www.mdpi.com/journal/ijerph
- Masekameni MD, Moyo D, Khoza N, Chamdimba C. 2020. Accessing occupational health services in the Southern African development community region. Int J Environ Res Public Health. [Internet]. 17(18):6767. [accessed 2020 Oct 25]. www.mdpi.com/journal/ijerph.
- Mathee A. 2011. Environment and health in South Africa: gains, losses, and opportunities. J Public Health Policy. Internet]. [accessed. [2020 Mar 24]. 32S1: S37–S43. www.palgrave-journals.com/jphp/
- Mathee A, Harpham T, Naicker N, Barnes B, Plagerson S, Feit M, Swart A, Naidoo S. 2010. Overcoming fieldwork challenges in urban health research in developing countries: a research note. Int J Soc Res Methodol. 13(2):171–178. doi:10.1080/13645570902867742.
- Mbachu A, Frei M. 2011. Diagnosing the strategic health of an organization from SWOT analysis results: case study of the Australasian cost management profession. Constr Manag Econ. [Internet]. 29(3):287–303. [accessed 2020 Sep 16]. https://www.tandfonline.com/action/journalInformation?journalCode=rcme20.
- Mboera LEG, Mfinanga SG, Karimuribo ED, Rumisha SF, Sindato C. 2014. The changing landscape of public health in sub-Saharan Africa: control and prevention of communicable diseases needs rethinking. Onderstepoort J Vet Res. [accessed 2020 Mar 29. 812. http://www.ojvr.org Internet.
- Mbola P, Human IS, Melariri PE. 2019. Environmental health community service: confronting the human resource challenges. SA J Hum Resour Manag. 17:1–10. doi:10.4102/sajhrm.v17i0.1135.
- Mbonane TP, Naicker N. 2020. Knowledge, attitude and practices of environmental health practitioners conducting food-borne disease outbreak investigation at a local municipality in Gauteng Province, South Africa. Heal SA Gesondheid. 25:1–8.
- Meerburg BG, Singleton GR, Kijlstra A. 2009. Critical reviews in microbiology rodent-borne diseases and their risks for public health Rodent-borne diseases and their risks for public health. Crit Rev Microbiol. [Internet]. 35(3):221–270. [accessed 2020 Sep 17]. https://www.tandfonline.com/action/journalInformation?journalCode=imby20
- Mehmood A, Aslam Mirza M, Aziz Choudhary M, Kim KH, Raza W, Raza N, Soo Lee S, Zhang M, Lee JH, Sarfraz M. 2019. Spatial distribution of heavy metals in crops in a wastewater irrigated zone and health risk assessment. Environ Res. [Internet]. 168:382–388. [accessed 2020 Oct 1]. doi:10.1016/j.envres.2018.09.020.
- Morakinyo O, Mokgobu M, Mukhola M, Hunter R. 2016. Health outcomes of exposure to biological and chemical components of inhalable and respirable particulate matter. Int J Environ Res Public Health. [Internet]. 13(6):592. [accessed 2020 Feb 23]. www.mdpi.com/journal/ijerph
- Moran M. 2016. The grand convergence: closing the divide between public health funding and global health needs. PLoS Biol. 14(3):1–11. doi:10.1371/journal.pbio.1002363.
- Morawska L, Milton DK. 2020. It is time to address airborne transmission of coronavirus disease 2019 (COVID-19). Clin Infect Dis. [Internet]. [accessed 2021 Sep 4]. https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1118/5891227
- Morse T, Chidziwisano K, Musoke D, Beattie TK, Mudaly S. 2020. Environmental health practitioners: a key cadre in the control of COVID-19 in sub-Saharan Africa. BMJ Glob Heal. [Internet]. 5:3314. [accessed 2020 Sep 6]. doi: 10.1136/bmjgh-2020-003314
- Muller E, Diab RD, Binedell M, Hounsome R. 2003. Health risk assessment of kerosene usage in an informal settlement in Durban, South Africa. Atmos Environ. 37(15):2015–2022. doi:10.1016/S1352-2310(03)00125-0.
- Musoke D, Ndejjo R, Atusingwize E, Halage AA. 2016. The role of environmental health in One Health: a Uganda perspective. One Heal. [Internet]. 2:157–160. [accessed 2020 Mar 29].doi:10.1016/j.onehlt.2016.10.003.
- Naidoo S. 2019. “Daylight robbery” by fake health inspectors in Port Shepstone. South Coast Her [Internet]. [ accessed 2020 Aug 22]. https://southcoastherald.co.za/356589/bogus-health-inspectors-arrested-or-daylight-robbery-by-fake-inspectors/
- National Department of Health. 2020. COVID-19: environmental health guidelines. 1–7.
- National Institute for Communicable Diseases. 2018. Situation report prepared by National Listeria Incident Management Team. Pretoria.
- Newman J, Cherney A, Head BW. 2016. Do policy makers use academic research? Reexamining the “two communities” theory of research utilization. Public Adm Rev. 76(1):24–32. doi:10.1111/puar.12464.
- Nikolaou EI, Ierapetritis D, Tsagarakis KP. 2011. An evaluation of the prospects of green entrepreneurship development using a SWOT analysis. Int J Sustain Dev World Ecol. [Internet]. 18(1):1–16. [accessed 2020 Sep 16] https://www.tandfonline.com/action/journalInformation?journalCode=tsdw20.
- Nweke OC, Sanders WH. 2009. Modern environmental health hazards: a public health issue of increasing significance in Africa. Environ Health Perspect. 117(6):863–870. doi:10.1289/ehp.0800126.
- O’ Marley R, Marsh AS, Negra C. 2009. Closing the environmental toxicology gap. Issues Sci Technol. [Internet]. 43(24):69–73. [accessed 2020 Sep 24] https://pubs.acs.org/doi/10.1021/es9033233
- Oosthuizen J, Ehrlich R. 2001. The impact of pollution from a mercury processing plant in KwaZulu-Natal, South Africa, on the health of fish-eating communities in the area: an environmental health risk assessment. Int J Environ Health Res. [Internet]. 11(1):41–50. [accessed 2020 Aug 25] https://www.tandfonline.com/action/journalInformation?journalCode=cije20.
- Papadopoulo P, Marouli C, Misseyanni A. 2019. Environmental exposures and human health [Internet]. First. Hershey (PA): IGI Global. [accessed 2020 Sep 6] http://sk.sagepub.com/reference/lifestylemedicinehealth/n127.xml
- Phillips LJ, Moya J. 2014. Exposure factors resources: contrasting EPA’s exposure factors handbook with international sources. J Expo Sci Environ Epidemiol. 24(3):233–243. doi:10.1038/jes.2013.17.
- Prüss-Ustün A, Wolf J, Corvalán C, Neville T, Bos R, Neira M. 2016. Diseases due to unhealthy environments: an updated estimate of the global burden of disease attributable to environmental determinants of health. J Public Health (Bangkok). [accessed 2020 Aug 22]. 393: 464–475. https://academic.oup.com/jpubhealth/article-abstract/39/3/464/3003007/Diseases-due-to-unhealthy-environments-an-updated Internet.
- Radu M. 2015. Political stability - A condition for sustainable growth in Romania? Procedia Econ Financ. [Internet]. [accessed 2020 Sep 17]. 30:751–757. www.sciencedirect.com
- Reid SJ. 2005. Community service for health professionals to improve services. South African Heal Rev. [Internet]. 135–160. Durban: Health Systems Trust. [accessed 2020 Mar 24]. http://www.vosesa.org.za/focus
- Reid SJ, Peacocke J, Kornik S, Wolvaardt G. 2018. Compulsory community service for doctors in South Africa: a 15-year review. South African Med J. 108(9):741–747. doi:10.7196/SAMJ.2018.v108i9.13070.
- Reinsberger K, Brudermann T, Hatzl S, Fleiß E, Posch A. 2015. Photovoltaic diffusion from the bottom-up: analytical investigation of critical factors. Appl Energy. [accessed 2020 Aug 21. 159: 178–187. doi:10.1016/j.apenergy.2015.08.117. Internet.
- Republic of South Africa. 1996. Consitution of the Republic of South Africa No. 108 of 1996. Pretoria.
- Resnick BA, Zablotsky J, Burke TA. 2009. Protecting and promoting the nation’s health: the environmental public health workforce as a critical component. J Public Health Manag Pract. 15(6 Suppl):40–45. doi:10.1097/PHH.0b013e3181b3492d.
- Rodrigues MA, Silva MV, Errett NA, Davis G, Lynch Z, Dhesi S, Hannelly T, Mitchell G, Dyjack D, Ross KE. 2021. How can environmental health practitioners contribute to ensure population safety and health during the COVID-19 pandemic? Saf Sci. [Internet]. 136:105136. [accessed 2021 May 25]. 10.1016/j.ssci.2020.105136.
- Selman CA, Green LR. 2008. Environmental health specialists’ self-reported foodborne illness outbreak investigation practices. J Environ Health. 70(6):16–20.
- Sen-Crowe B, McKenney M, Elkbuli A. 2020. Public health prevention and emergency preparedness funding in the United States: are we ready for the next pandemic? Ann Med Surg. 59(October):242–244. Internet. doi:10.1016/j.amsu.2020.10.007.
- Shezi B, Mathee A, Siziba W, Street RA, Naicker N, Kunene Z, Wright CY. 2019. Environmental health practitioners potentially play a key role in helping communities adapt to climate change. BMC Public Health. [Internet]. [accessed 2020 Mar 24]. 19(1):54. doi:10.1186/s12889-018-6378-5.
- Shonhiwa AM, Ntshoe G, Essel V, Thomas J, McCarthy K. 2019. A review of foodborne diseases outbreaks reported to the outbreak response unit, national institute for communicable diseases, South Africa, 2013–2017. Int J Infect Dis. [Internet]. 79(2019):73. doi:10.1016/j.ijid.2018.11.186.
- Shumetie A, Watabaji MD. 2019. Effect of corruption and political instability on enterprises’ innovativeness in Ethiopia: pooled data based. J Innov Entrep. 8(1):11. [accessed 2020 Aug 21]. doi:10.1186/s13731-019-0107-x [Internet. doi:.
- Sly PD, Carpenter DO, Van den Berg M, Stein RT, Landrigan PJ, Brune-Drisse M-N, Suk W. 2016. Health consequences of environmental exposures: causal thinking in global environmental epidemiology. Ann Glob Heal. [Internet]. 82(1):3. [accessed 2019 Aug 15]. https://annalsofglobalhealth.org/articles/10.1016/j.aogh.2016.01.004
- Statistics South Africa. 2019. Inequality Trends in South Africa: a multidimensional diagnostic of inequality [Internet]. Pretoria; [ accessed 2020 Sep 27]. www.statssa.gov.za
- Statistics South Africa. 2020. Population (mid-year estimate) 2019 [Internet]. [ accessed 2020 May 12]. http://www.statssa.gov.za/
- Strand TM, Lundkvist Å. 2019. Rat-borne diseases at the horizon. A systematic review on infectious agents carried by rats in Europe 1995–2016. Infect Ecol Epidemiol. 9(1):1553461. Internet. doi:10.1080/20008686.2018.1553461.
- Thamrin H, Pamungkas EW 2017. A rule based SWOT analysis application: a case study for Indonesian Higher Education Institution. In: 2nd Int Conf Comput Sci Comput Intell Internet; Vol. 116. Indonesia; [accessed 2020 Aug 9]; p. 144–150. www.sciencedirect.comwww.sciencedirect.comwww.elsevier.com/locate/procedia
- Thomas EP, Seager JR, Mathee A. 2002. Environmental health challenges in South Africa: policy lessons from case studies. Heal Place. [accessed 2020 Aug 12]. 84: 251–261. http://hst.org.za/hlink/equity.asp Internet.
- Turpin BJ, Weisel CP, Morandi M, Colome S, Stock T, Eisenreich S, Buckley B. 2007. Relationships of indoor, outdoor, and personal air (RIOPA): part II. Analyses of concentrations of particulate matter species. Res Rep Health Eff Inst, 130 Pt 2. 1–110
- Van Durme T, Macq J, Anthierens S, Symons L, Schmitz O, Paulus D, Van den Heede K, Remmen R. 2014. Stakeholders’ perception on the organization of chronic care: a SWOT analysis to draft avenues for health care reforms. BMC Health Serv Res. [Internet]. [accessed 2020 Sep 12]. 141. http://www.biomedcentral.com/1472-6963/14/179
- Vardoulakis S, Dear K, Wilkinson P. 2016. Challenges and opportunities for urban environmental health and sustainability: the HEALTHY-POLIS initiative. Environ Heal A Glob Access Sci Source. 15(Suppl 1):1–5.
- Weis BK, Balshaw D, Barr JR, Brown D, Ellisman M, Lioy P, Omenn G, Potter JD, Smith MT, Sohn L, et al. 2005. Personalized exposure assessment: promising approaches for human environmental health research. Environ Health Perspect. [Internet]. [accessed 2020 Mar 24]. 1137: 840–848. doi:10.1289/ehp.7651.
- Whiley H, Willis E, Smith J, Ross K. 2019. Environmental health in Australia: overlooked and underrated. J Public Health (Bangkok). [accessed 2020 Mar 24]. 413: 470–475. https://academic.oup.com/jpubhealth/article-abstract/41/3/470/5115854 Internet.
- World Health Organization. 2016a. Environmental impacts on health: what is the big picture? WHO. Geneva. [Internet]. [accessed 2020 Jan 22]. https://www.who.int/quantifying_ehimpacts/publications/PHE-prevention-diseases-infographic-EN.pdf?ua=1
- World Health Organization. 2016b. The public health impact of chemicals: knowns and unknowns. WHO. Geneva. [Internet]. [accessed 2020 May 13]. http://apps.who.int/iris/bitstream/handle/10665/206553/WHO_FWC_PHE_EPE_16.01_eng.pdf?sequence=1.
- World Health Organization. 2018. WHO Listeriosis – South Africa. WHO. [Internet]. [accessed 2020 May 13]. https://www.who.int/csr/don/28-march-2018-listeriosis-south-africa/en/
- Wright CY, Dominick F, Kunene Z, Kapwata T, Street RA. 2017. Bibliometric trends of South African environmental health articles between 1998 and 2015: making local research visible and retrievable. South African Med J. 107(10):915–924. doi:10.7196/SAMJ.2017.v107i10.12429.
- Wright CY, Mathee A, Oosthuizen MA. 2014. Challenging times for environmental health in South Africa: the role of the environmental health research network. South African Med J. 104(1):20–21. doi:10.7196/SAMJ.7287.
- Writer S. 2018. City of Cape Town warns against fake health officials scamming business owners. Sme South Africa [Internet]. [ accessed 2020 Aug 22]. https://smesouthafrica.co.za/city-of-cape-town-warns-against-fake-health-officials-scamming-business-owners/
- Yang X, Lo K, Lam DC. 2021. Environmental health research and the COVID-19 pandemic: a turning point towards sustainability. Environ Res. [Internet]. [accessed 2021 May 16]. 197: 111157. doi:10.1016/j.envres.2021.111157.
- Zhou L, Nhundu K, Tesfamichael S. 2016. Solid waste management in South Africa: a case of Alice in Nkonkobe local municipality, Eastern Cape Province. J Public Adm. [Internet] 51(3):350–360. [accessed 2020 Sep 16] https://journals.co.za/docserver/fulltext/jpad/51/3/jpad_v51_n3_a3.pdf?expires=1550033539&id=id&accname=58211&checksum=EA79BE6C5254583D2D9D2B62CED946C0