The English version of the October 2026 issue of the Journal of Environmental Health (Volume 89, Number 3), published by the National Environmental Health Association.
Environmental Health To build, sustain, and empower an effective environmental health workforce Volume 89, No. 3 October 2026 Journal of
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Published by the National Environmental Health Association
Environmental Health To build, sustain, and empower an effective environmental health workforce Volume 89, No. 3 October 2026 Journal of
ADVANCEMENT OF THE SCIENCE
ABOUT THE COVER
Assessing Knowledge and Awareness of Nitrate Contamination: A Survey of Healthcare Professionals..........................................................................................................8
Air pollution is a well-established threat to human health, but its effects could extend to broader social and behav- ioral outcomes. This month’s cover article examines
From Air Quality to Public Safety: Rethinking Crime Dynamics and Social Costs of Pollution in the United States.....................................................................................................18
International Perspectives: Behavioral Approaches of Households to Address Waterborne Diseases in Children in Suburban Bangladesh .............................................................................. 26
the relationship between fine particulate matter (PM 2.5 ), socioeconomic conditions, and crime rates across 10 highly polluted U.S. states from 2000–2022. After accounting for differences among states and changes over time, the study found a significant positive association between PM2.5 concentrations and crime rates. Although the findings do not establish causal- ity, they offer a broader perspective on the potential social costs of pollution and the inter- connected benefits of improving air quality. See page 18. Cover images © iStockphoto: maystra; ConceptCafe
ADVANCEMENT OF THE PRACTICE
Direct From CDC/Environmental Health Services: Building National Capacity: Tools and Re- sources for the Environmental Health Professional ....................................................................... 36
Spotlight on Success Stories From the Field: Beyond Compliance: How Meeting FDA Voluntary National Retail Food Regulatory Program Standards Strengthened Our Retail Food Program . ........................................................................................................... 40
ADVANCEMENT OF THE PRACTITIONER
Environmental Health Calendar................................................................................................44
ADVERTISERS INDEX
People on the Move...................................................................................................................46
Climate for Health Ambassador Training.............45 EHLR Certificate Program....................................39 Handheld Scientific Systems...................................2 Hedgerow Software...............................................55 HS GovTech..........................................................56 JEH Advertising..................................................... 45 NEHA CP-FS Credential.......................................42 NEHA CP-FS Study Guide....................................43 NEHA Credentials................................................16 NEHA Endowment Foundation Donors..............35 NEHA HACCP Training........................................43 NEHA Membership................................................4 NEHA REHS/RS Online Study Course.................17 NEHA REHS/RS Study Guide...............................17 NEHA/AAS Scholarship Fund Donors....................5
JEH Quiz #2...............................................................................................................................47
Spotlight on NEHA Resources: Community ............................................................................... 48
YOUR ASSOCIATION
President’s Message: Rule #1 in Environmental Health: Expect the Unexpected! . .................................... 6
NEHA AEC 2027.......................................................................................................................49
Special Listing............................................................................................................................50
NEHA News...............................................................................................................................52
NEHA Member Spotlight...........................................................................................................54
3
October 2026 • Journal of Environmental Health
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Journal of Environmental Health (ISSN 0022-0892)
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Kristen Ruby-Cisneros, Managing Editor Ellen Kuwana, MS, Assistant Editor Hughes design|communications, Design/Production Cognition Studio, Cover Artwork Soni Fink, Advertising For advertising call (303) 802-2139 Technical Editors William A. Adler, MPH, RS Retired (Minnesota Department of Health), Rochester, MN Gary Erbeck, MPH
h Building a Multisectoral Coalition to Prevent Lead Exposure in Ethiopia
h Development of a Spatial Noise Map and Perceived Health Risks for Itinerant Workers in Lagos, Nigeria
Retired (County of San Diego Department of Environmental Health), San Diego, CA Thomas H. Hatfield, DrPH, REHS, DAAS California State University, Northridge, CA Dhitinut Ratnapradipa, PhD, MCHES Creighton University, Omaha, NE
h National Census of Retail Food Inspector Standardization in the United States
4
Volume 89 • Number 3
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5
October 2026 • Journal of Environmental Health
YOUR ASSOCIATION
Open Access
PRESIDENT’S MESSAGE
Rule #1 in Environmental Health: Expect the Unexpected!
Scott E. Holmes, MS, REHS
H ave you ever returned from conduct- ing a “routine” inspection and ex- claimed, “You won’t believe what I saw today!” Here are just a few unexpected things my staff found while doing “routine” inspections: • Unrefrigerated seafood stored for days in a van in the summer (ick). • A self-installed septic system with a single “lateral” discharging to a nearby creek. • A pool with 0 ppm chlorine and a broken chlorination system. The pool operator knew the chlorinator had failed a few days ago and was “waiting for parts.” • Very old, potentially explosive and toxic chemicals discovered during a food inspec- tion in the basement of a grocery store that was once a compounding pharmacy. Pic- ture in your mind crystallized picric acid, arsenic, and mercury compounds. The response involved environmental health and fire hazardous materials (hazmat) teams, police to evacuate adjacent build- ings and close off streets, and the bomb squad, who had a very cool robot that, unfortunately, could not do stairs. • A directional sound-generating device used by neighbor A to intentionally aggra- vate neighbor B. Neighbor B sold their property, sued neighbor A, and won. • Snakes in a well. (Really? Yes, really!) (Photo 1). Unexpected events in environmental health often seem so random. Can you pre- pare for them? I believe you can by building, sustaining, and empowering yourself, but more on that after a couple of real-life envi- ronmental health stories of the unexpected.
• Overall, four of the five ill children were in the same grade, and the other child was a sibling. • The ill teacher taught three of the five ill children. • Staff who became ill worked in or near the health office. • No pesticides or chemicals had been used in the school or on the grounds. The external environmental health rapid assessment did not identify anything unusual. The internal assessment, however, was a dif- ferent story. As we walked down the hallway near the affected students’ classrooms, we noticed a very slight odor. To me, the faint floral fragrance smelled like perfume. Mike, our experienced indoor air quality specialist who had a bloodhound-like nose for iden- tifying chemical odors, turned to me with a twinkle in his eye and said, “Pyrethrins!” Peering into a classroom, we saw children working on a special art project—making a beautiful bouquet of daisies to take home to their family. Students were handling the flow- ers, cutting and plucking leaves off the stems, and creating their own unique bouquet. Most appeared to be having great fun. We heard a couple of sneezes, and a few students had runny noses and watery eyes. Mike quickly explained that some varieties of daisies have natural pyrethrin in their stems. Handling the flowers, plucking leaves, and cutting stems would expose hands directly and release pyrethrin into the air, where it could be inhaled. Children and adults allergic to pyre- thrin would have an immediate IgE immune response (Type I hypersensitivity). The health aide was likely exposed while examining chil-
Flower Power One Friday afternoon before Mother’s Day, a school nurse called the environmental health department. Her voice was strained. Within minutes of each other, five students and two staff came to her health office with similar symptoms: itching, stinging skin, difficulty breathing, and dizziness. Her health aide quickly developed similar symptoms, but the nurse was not affected. She thought it must be an allergic reaction. With a single phone call, our TGIF mood switched to emergency response (ER) mode. Our ER Team met STAT (don’t you love acronyms!). We suspected a chemical expo- sure, perhaps a pesticide. The risk was high. Children were affected. Could this wave be the first of more illnesses? We quickly drove to the school. When we arrived, we formed two strike teams. One team interviewed those affected, and the other conducted a rapid environmental health assessment of the school. We found several clues to unlocking this environmental health mystery: Unexpected events in environmental health often seem so random. Can you prepare for them? I believe you can.
6
Volume 89 • Number 3
https://doi.org/10.70387/001c.171783
ordered heavy metal testing. Art had mercury poisoning. Jessica was tested and found to have mercury poisoning also. The doctor called our health department, and we immediately launched an investiga- tion into the potential source of mercury poi- soning. Since the cat, Art, and Jessica were not sick until they moved into the house, it seemed like the most obvious place to start. Our hazmat response team was deployed to the house. We immediately detected mer- cury on arrival and throughout the house. The highest mercury levels were found in the entryway and carpet. Further research and investigation sug- gested that a previous renter might have applied mercury around the door frame, per- haps to ward off evil spirits. The cat likely had the highest dose due to direct paw con- tact with carpet, a low breathing zone, and licking fur. As my toxicologist friend Sue Dempsey says, “The dose makes the poison.” Remediation of the house cost thousands of dollars. Both Art and Jessica had chelation therapy and recovered fully. Unfortunately, their vehicle and most of their belongings could not be salvaged, and they had to with- draw from college. How Can You Be Prepared for the Unexpected? Build, sustain, and empower yourself! Build on your education foundation! The foundation of environmental health is science. If you are short on science credits, add a few bricks (college science classes) to your foundation. If your foundation is strong, build on it by pursuing a certificate or creden- tial in environmental health or public health. Or go all-in and commit to finally earning your master’s degree in environmental health, public health, or another related field.
every area in environmental health. Enhance your incident response training and partici- pate in tabletop and full-scale field exercises. Take hazmat awareness-level training; it could save your life and teach you when to call the bomb squad. Sign up for the highly rated, in-person Environmental Health Train- ing in Emergency Response from the Centers for Disease Control and Prevention. • Sign up for NEHA’s Grand Rounds and dozens of other online training opportu- nities available through NEHA and other federal agencies. • If you already hold NEHA’s Registered Environmental Health Specialist/Regis- tered Sanitarian (REHS/RS) credential, congratulations! If not, commit to obtain- ing your REHS/RS. Empower Yourself Through Professional Development • Read the Journal of Environmental Health and EH In Focus emails, and subscribe to podcasts and listservs that broaden your mind and keep your curiosity active. • Submit your application for the next NEHA Environmental Health Leadership Academy cohort. • Join the conversation on NEHA’s online Community. • Become more active in NEHA or your state affiliate—opportunities abound. • Decide today to attend NEHA’s 2027 Annual Educational Conference & Exhibi- tion in Portland, Oregon.
dren. We reinterviewed the health aide, and she knew she was allergic to pyrethrin. Envi- ronmental health unexpected mystery event #24.7.365 solved! The Cat Was the Canary Jessica and Art moved to our community to attend college. They felt lucky to find a small, pet-friendly house to rent near the college. Everything seemed great at first, but soon their cat had vomiting, diarrhea, and trouble breathing. They took the cat to a veterinarian, who treated the symptoms, but 2 days later their beloved cat died. Over the next 2 weeks, first Art and then Jessica developed similar symptoms. One night, Art could not catch his breath, and Jessica rushed him to the hospital. She told the doctor she was very scared—their cat had similar symptoms and then died. Art was admitted, and a very astute hospitalist Photo 1. Michael Gude, REHS, a senior environmental health specialist with the Lincoln–Lancaster County Health Department, displays a snake pulled from a local water well. Photo courtesy of the Lincoln–Lancaster County Health Department.
You Can Prepare for the Unexpected
You can prepare for the unexpected through education, training, and professional devel- opment. NEHA is here to help build, sustain, and empower you. Together, we are the envi- ronmental health workforce.
Sustain Yourself Through Training!
Pursue training in areas such as toxicology and risk communication, which apply to
sholmes@neha.org
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7
October 2026 • Journal of Environmental Health
ADVANCEMENT OF THE SCIENCE
Open Access
Assessing Knowledge and Awareness of Nitrate Contamination: A Survey of Healthcare Professionals
85% of the state’s population depends on groundwater for their drinking water sup- ply (Nebraska Department of Environment and Energy, 2024). Although the Safe Drinking Water Act maintains a regulatory maximum contami- nant level (MCL) of 10.0 mg/L for nitrate/ nitrite to reduce the risk of methemoglo- binemia, evidence suggests that a variety of other adverse health outcomes can result from nitrate in drinking water. Some studies show an increased risk with concentrations lower than the current regulatory MCL (U.S. Environmental Protection Agency, 2025). Statewide Domestic Water/ Wastewater Management, University of Nebraska–Lincoln, Nebraska Extension in Lancaster County School of Natural Resources, University of Nebraska–Lincoln Jesse E. Bell, PhD College of Public Health, University of Nebraska Medical Center School of Natural Resources, University of Nebraska–Lincoln Daugherty Water for Food Global Institute, University of Nebraska Krista A. Brown, MBA, MPH, PhD College of Public Health, University of Nebraska Medical Center Daugherty Water for Food Global Institute, University of Nebraska Summer Woolsey, MPH College of Public Health, University of Nebraska Medical Center Justin Baumert College of Medicine, University of Nebraska Medical Center Jessenia Hincapie, MPH Great Plains IDeA-CTR Network, University of Nebraska Medical Center Ruth Mencia, MPH College of Public Health, University of Nebraska Medical Center Laura Nagengast, MPH Great Plains IDeA-CTR Network, University of Nebraska Medical Center Anni Poetzl, MSc Nebraska Extension, Water and Cropping Systems, University of Nebraska–Lincoln Becky M. Schuerman
Abstract Our study assessed the knowledge, attitudes, and confidence of healthcare professionals (HCPs) about nitrate contamination of drinking water and adverse health outcomes. A cross-sectional survey was administered ( n = 689). Descriptive statistics, nonparametric tests, and linear regression were used to compare means in behavior and examine the effect of knowledge and attitudes on information-sharing practices with patients. Qualitative analysis of open-ended questions identified gaps in knowledge, current access to resources, and preferences for future training and resources. Participants reported a lack of knowledge about the detrimental health effects of nitrates and low confidence in advising their patients about drinking water quality. Participant attitude was a strong and significant predictor of information-sharing behaviors ( B = 0.624, p < .001). Participants also reported a need for additional knowledge and resources via educational videos, virtual training, and websites. Future research should develop targeted interventions to provide education and training for HCPs about nitrate contamination and its effect on adverse health outcomes. Keywords: nitrate, water quality, healthcare workers, drinking water, healthcare survey
Introduction In Nebraska, nearly 44 million acres—an estimated 90% of the state—are dedicated to farming and ranching. To sustain high lev- els of agricultural production, Nebraska and seven other states within the High Plains aqui- fer depend heavily on groundwater resources that support large-scale irrigation (Scanlon et al., 2012). As of 2023, more than 8.4 million acres of land in Nebraska are irrigated with groundwater, making it one of the most irri- gated states in the country (Nebraska Depart- ment of Agriculture, n.d.). In addition to a reliance on irrigation, Nebraska’s producers regularly apply fertil- izers in the forms of manufactured fertil- izer, manure, and biosolids to maximize
crop yields. Because nitrate is highly soluble, excess amounts can easily move with precipi- tation and irrigation runoff and leach away from the soil, ultimately accumulating in groundwater (Jayasekera et al., 2025; Wick et al., 2012). Being dependent on both irriga- tion and fertilizers places Nebraska’s ground- water at significant risk of nitrate contamina- tion (U.S. Geological Survey, 1999). Nitrate contamination in drinking water is a growing public health concern, as nitrate in fertilizers and animal waste can run off the land and contaminate local waterbodies. As a result, individuals living in rural areas are at higher risk of exposure to contami- nated drinking water than their urban coun- terparts (Skalaban et al., 2024). More than
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Volume 89 • Number 3
https://doi.org/10.70387/001c.171784
For pregnant individuals exposed to nitrate concentrations ranging between 5 mg/L and 10 mg/L, the increased risk of spontaneous birth between 20 weeks and 31 weeks of ges- tation was found to be as high as 47% (Lin et al., 2023; Sherris et al., 2021). Nitrate expo- sure during pregnancy has also been linked to elevated risks for birth defects of the eye, ear, face, and neck (Stayner et al., 2022). Beyond infancy and pregnancy, there is also evidence connecting nitrate exposure to pediatric and adult cancers. Regions in Nebraska with watersheds that have average nitrate levels >10 mg/L have a higher-than- average incidence of pediatric cancers of the central nervous system (Ouattara et al., 2022). Additionally, Nebraska counties with nitrate concentrations between 2.1 mg/L and 5.0 mg/L had significantly higher incidence rates of pediatric brain and central nervous system cancers and leukemia and lymphoma compared with Nebraska counties with nitrate concentrations between 0 mg/L and 2.0 mg/L (Ouattara et al., 2022). Nitrate exposure from contaminated water has also been linked to adult cancers, includ- ing gastric and colorectal cancers, and other serious health problems such as thyroid dis- ease (Grout et al., 2023; Picetti et al., 2022; Shapiro et al., 1991; Ward et al., 2018). The association between nitrate-contaminated water and these health problems underscores the need for ongoing research to understand the complex factors influencing nitrate expo- sure and its related detrimental effects among residents who rely on private well water. Healthcare professionals (HCPs) often inter- act with patients who are at a higher risk of being exposed to high nitrate concentrations from private well water, making these HCPs an ideal population to educate and inform private well owners of the importance of testing their well water. To address this gap, our study aim was to explore HCP 1) knowledge of, attitudes about, and awareness of nitrate contamination in drinking water and its associated health risks and 2) confidence in identifying, pre- venting, and treating patients exposed to poor drinking water quality. Methods We used a cross-sectional survey design to assess the knowledge, attitudes, awareness, and confidence levels of HCPs. We selected HCPs for this study because prior research
has demonstrated that they are seen by the public as a trusted source of information on environmental health issues, including water quality (Dutta-Bergman, 2003; Guidotti & Ragain, 2008; Peters et al., 2022). Participants and Recruitment The Bureau of Sociological Research (BOSR) at the University of Nebraska–Lincoln (UNL) identified eligible participants and adminis- tered the survey. Eligible participants were all osteopathic physicians/surgeons, physi- cians, physician assistants, advanced prac- tice registered nurse (APRN) practitioners, and registered nurses with a current license in Nebraska ( N = 53,592). From this initial list, eligible participants were pared down to participants with an address in Nebraska, bringing the number of potential participants to 38,710. Participants were excluded if they were retired, not currently seeing patients, or not practicing medicine in Nebraska. Survey Development The Healthcare Professional Drinking Water Survey (HP-DWS) was developed for this study and included topics related to cur- rent knowledge, opinions, practices, and resource availability about drinking water quality. The HP-DWS consists of 52 ques- tions, including yes/no responses, Lik- ert scales, multiple-choice questions, and open-ended responses. The face and content validity of the HP-DWS in this study were good; further validity and reliability will be presented in a separate article. The survey was programmed and adminis- tered via Qualtrics. Data were collected from September 30, 2024, to November 8, 2024, and the survey was available in English. A total of 689 HCPs completed the survey out of a total of 38,710 potential participants, for a response rate of 1.8% using the standard definitions (American Association for Pub- lic Opinion Research, 2023). In this article, we present data for HCPs who practice in Nebraska ( n = 689) and a subcohort selected for limited analysis ( n = 488). Statistical Analysis Data were cleaned to remove any blank responses or surveys completed by individu- als who did not match the inclusion criteria (i.e., retired, not currently seeing patients, or had already completed the survey). For the
analysis, some questions were recoded from a Likert scale to a binary response. Descrip- tive statistics, including frequency distribu- tions, were conducted. IBM SPSS Statistics 29.0.2.0 and StataSE Version 16 were used for statistical analyses. An additional analy- sis was conducted on a subcohort of par- ticipants ( n = 488) using linear regression to explore the effect of knowledge and attitudes on behaviors related to information sharing with patients. The qualitative method used a two-phase approach: 1) a deductive approach to identify written responses that could be coded into previously existing categories and 2) an inductive approach in which the remaining responses were carefully read and new categories were determined based on recurring themes. Results Of the participants who practiced medicine in Nebraska ( n = 689), a variety of HCP types and specialties were reported (Table 1). For the analysis, HCP types were grouped into two categories: physicians/physician assis- tants and nurse practitioners/registered nurses. Findings from the survey were cat- egorized into the domains of knowledge, atti- tudes, and awareness; behaviors and open- ness to change; and confidence. Additionally, data were collected on existing access to materials and preferences toward receiving materials in the future. Knowledge Domain HCPs were evaluated on their knowledge related to nitrate exposure and contamination in drinking water. Participants were asked to rate their knowledge of the adverse health effects of nitrate contamination in drinking water, if they had received any formal train- ing or education on water quality topics, and the hours of formal education or training received on poor drinking water quality and related health outcomes. Of the participants, 51.3% of physicians/ physician assistants and 56.8% of nurse prac- titioners/registered nurses reported they were “not at all knowledgeable” about the adverse health effects of nitrate contamination in drinking water ( χ ² = 1.552; p = .213) (Table 2). When asked if they had received formal education or training on any topics related to drinking water, 91.4% of physicians/phy- sician assistants and 95.8% of nurse practi-
9
October 2026 • Journal of Environmental Health
ADVANCEMENT OF THE SCIENCE
TABLE 1
Study Participant Demographics and Clinic Characteristics
Demographic
Full Sample ( n = 689)
Limited Analytic Sample ( n = 488)
#
%
#
%
Current occupation Physician
188
27.3
143
29.3
Physician assistant
30
4.4
26
5.3
Nurse practitioner
48
7.0
34
7.0
Registered nurse
402
58.3
285
58.4
Other
21
3.0
0
0
How often do you see patients who live in each of the following areas: Urban (≥50,000 people) Never 54
8.3
42
8.9
Rarely
77
11.9
60
12.8
Sometimes
57
8.8
41
8.7
Often
261
40.3
192
40.9
Always
198
30.6
135
28.7
Large rural/suburban (10,000–49,999 people) Never
42
6.6
33
7.1
Rarely
48
7.6
34
7.4
Sometimes
131
20.7
95
20.6
Often
288
45.4
212
45.9
Always
125
19.7
88
19.0
Small rural (≤9,999 people) Never
34
5.3
29
6.2
Rarely
67
10.5
49
10.4
Sometimes
180
28.1
131
27.9
Often
224
35.0
167
35.6
Always
135
21.1
93
19.8
Type of current practice Hospital-based
356
51.7
246
50.4
Clinic-based
244
35.4
182
37.3
Multispecialty clinic
28
4.1
15
3.1
Group practice
36
5.2
20
4.1
None of these descriptions
98
14.2
72
14.8
Number of patients seen in an average week 0
0
0
0
0
1–15
191
27.7
140
28.7
16–30
163
23.7
110
22.5
31–45
109
15.8
74
15.2
46–50
62
9.0
49
10.0
≥51
164
23.8
115
23.6
10
Volume 89 • Number 3
TABLE 2
Mean Differences for Survey Domains: Knowledge, Behavior, Attitude, Confidence, and Access to Materials
Survey Domain
Physician/Physician Assistant
Nurse Practitioner/ Registered Nurse
Mean Difference (Mann–Whitney U -test/ Z -test/)
#
M SD
#
M SD U Statistic
Z -Score
p -Value
Knowledge
Knowledge about nitrate-contaminated drinking water Received formal education/training on any water quality topics
189
0.487 0.501
414
0.432 0.496
36,994.5
-1.245
.213
185
0.086 0.282
383
0.042 0.200
33,843.5
-2.164
.030
Hours of formal education/ training received
11
1.500 1.643
10
1.650 1.651
–
–
–
Behavior/openness to change
Participant plans for future education/ training on the adverse health effects of nitrate-contaminated water Likelihood that participants would use resources on drinking water quality if they were available Likelihood that participants would distribute resources on drinking water quality if resources were available
184
0.217 0.414
379
0.253 0.435
33,616.0
-0.933
.351
184
0.587 0.494
372
0.715 0.452
29,840.0
-3.026
.002
181
0.459 0.500
368
0.590 0.493
28,937.5
-2.898
.004
Attitudes/awareness
Frequency in which participants discuss the adverse health effects of nitrate contamination with patients
185
0.195 0.397
382
0.181 0.385
34,841.5
-0.401
.688
Participant levels of concern for their patients regarding nitrate- contaminated water
184
0.783 0.414
376
0.811 0.392
33,604.0
-0.796
.426
Participant prioritization of educating patients on the risks of drinking nitrate- contaminated water
175
0.743 0.438
348
0.776 0.418
29,445.0
-0.839
.401
Confidence
Participant confidence in advising patients about the adverse health effects of nitrate contamination in drinking water Participant confidence in referring patients to the appropriate resources should they be concerned about their drinking water quality Participant confidence in treating patients for the adverse health effects of nitrate contamination in drinking water
187
0.289 0.454
395
0.281 0.450
36,646.0
-0.194
.846
185
0.438 0.497
390
0.462 0.499
35,220.0
-0.533
.594
185
0.168 0.374
384
0.260 0.439
32,222.0
-2.462
.014
Access to materials
Participant access to resources about the adverse health effects of nitrate contamination in drinking water
183
0.208 0.407
371
0.191 0.394
33,394.0
-0.453
.651
11
October 2026 • Journal of Environmental Health
ADVANCEMENT OF THE SCIENCE
FIGURE 1
Formal Education Received on Water Quality Topics
Physicians ( n = 183)
9.8
90.2
Physician Assistants ( n = 28)
3.6
96.4
Nurse Practitioners ( n = 55)
7.3
92.7
Registered Nurses ( n = 349)
4.6
95.4
0
10
20
30
70
80
90
100
40
50
60
% of Participant Responses
Yes No
tioners/registered nurses responded they had not (Figure 1). No statistically significant dif- ferences were found when comparing mean differences between physicians/physician assistants and nurse practitioners/registered nurses for either of these responses. Attitudes and Awareness Domain Attitudes toward and awareness of nitrate contamination in drinking water were assessed to determine how physicians/phy- sician assistants and nurse practitioners/ registered nurses felt when discussing these issues with patients. Participants were asked how often they discussed the health risks of nitrate contamination in drinking water with their patients, how concerned they were about nitrate-contaminated water as it relates
to their patients’ health, and how much of a priority it was for them to educate their patients about the risks of drinking nitrate- contaminated water. Most physicians/physician assistants and nurse practitioners/registered nurses reported that they never discussed the health risks of nitrate contamination with patients (80.5% and 81.9%, respectively). When asked about their level of concern about nitrate-contam- inated water, 78.3% of physicians/physician assistants and 81.1% of nurse practitioners/ registered nurses reported being “somewhat” to “very concerned” ( χ ² = 0.634; p = .426). Despite reporting a high level of concern for nitrate contamination, 25.7% of physicians/ physician assistants and 22.4% of nurse prac- titioners/registered nurses reported that they
believed this issue was not a priority in their practice ( χ ² = 0.705; p = .401).
Behaviors and Openness to Change Domain
Exploring the opportunity for future inter- ventions, participants rated their current behaviors and openness to behavior change regarding nitrate contamination education with their patients. To capture openness to change, participants were asked if they planned to receive any formal education or training on the health risks of consuming nitrate-contaminated water, how likely they would be to use resources for HCP training and education on drinking water quality (should they be made available), and how likely they would be to distribute these edu-
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Volume 89 • Number 3
FIGURE 2
Likelihood of A) Nurse Practitioners/Registered Nurses and B) Physicians/Physician Assistants Distributing Educational Resources on Drinking Water Quality to Patients
A) Nurse Practitioners/Registered Nurses ( n = 319)
B) Physicians/Physician Assistants ( n = 169)
Not at All Likely 9%
Not at All Likely 13%
Very Likely 17%
Very Likely 23%
Somewhat Likely 29%
Likely 27%
Somewhat Likely 43%
Likely 39%
cational resources on drinking water quality to patients. A majority of participants for both phy- sicians/physician assistants (78.3%) and nurse practitioners/registered nurses (74.7%) responded that they were not planning on receiving any formal education or training on the health risks of consuming nitrate-contam- inated water ( χ ² = 0.872; p = .351). When eval- uated for behavior and openness to change, 58.7% of physicians/physician assistants and 71.5% of nurse practitioners/registered nurses reported that they would be “likely” to “very likely” to use resources if these were made available ( χ ² = 9.174; p = .002). Responses were mixed, however, when participants were asked about their likeli- hood of distributing educational resources on drinking water quality to patients, with 54.1% of physicians/physician assistants stat- ing that they would be “somewhat” to “not at all likely” to do so. In contrast, 59.0% of the nurse practitioners/registered nurses stated that they would be “likely” or “very likely” to distribute these resources if made available ( χ ² = 8.415; p = .004) (Figure 2). Confidence Domain Participants were also asked to rate their level of confidence related to patient care and nitrate contamination in drinking water. Participants were asked, based on their cur- rent knowledge, how confident they were in
advising their patients about the health risks of nitrate contamination in drinking water, how confident they were in referring patients to appropriate resources if the patients were concerned about their drinking water quality, and how confident the HCPs were in treating patients for the adverse effects of nitrate con- tamination in their drinking water. When asked to rate their confidence in advising patients about the health risks of nitrate contamination in drinking water, 71.1% of physicians/physician assistants and 71.9% of nurse practitioners/registered nurses stated that they were “not at all con- fident” ( χ ² = 0.038; p = .846). Both groups reported being “not at all confident” in refer- ring patients to appropriate resources (56.2% of physicians/physician assistants and 53.8% of nurse practitioners/registered nurses). Last, when asked about their confidence in treating patients for the adverse health effects of nitrate contamination in drinking water, 83.2% of physicians/physician assistants and 74.0% of nurse practitioners/registered nurses reported being “not at all confident” in doing so ( χ ² = 6.073; p = .014). Access to and Preferences for Educational Materials and Training To gauge the current availability of water qual- ity-related resources, participants were asked if they currently had access to resources to learn more about the adverse health effects of nitrate
contamination in drinking water. The majority of physicians/physician assistants (79.2%) and nurse practitioners/registered nurses (80.9%) stated that they did not have access to these educational materials ( χ ² = 0.205; p = .650). Participants were then asked to select their preference for various types of educational materials that they would be interested in using to learn more about the health risks of consuming nitrate-contaminated drink- ing water. Physicians/physician assistants reported that they would be most interested in receiving educational materials and train- ing via a resource website, educational vid- eos, virtual training, and informational fly- ers. Nurse practitioners/registered nurses reported similar preferences, with a resource website, virtual training, educational vid- eos, and brochures being the most preferred. Mean differences between types of educa- tional material varied largely between the two participant groups, suggesting that HCP type should be considered when developing mate- rials and selecting the mode of delivery. Effect of Knowledge and Attitudes on Information-Sharing Behaviors To explore the effect of knowledge and atti- tudes on reported information-sharing behav- iors, a linear regression analysis was con- ducted. Results showed that knowledge was not a strong indicator of information-sharing behaviors ( B = 0.064), nor was it significant
13
October 2026 • Journal of Environmental Health
ADVANCEMENT OF THE SCIENCE
TABLE 3
Effect of Knowledge and Attitude on Information-Sharing Behaviors
Predictor
B
SE
p -Value
95% Confidence Interval
F
Partial η ²
Occupation Knowledge
0.056 0.064 0.624
0.021 0.052 0.042
.008 .220
[0.015, 0.096] [-0.038, 0.166] [0.542, 0.705]
7.180 1.508
0.015 0.003 0.318
Attitude
<.001
225.693
Note. R 2 = .357 and adjusted R 2 = .353.
( p = .220), and attitude was the strongest ( B = 0.624) and most significant ( p < .001) predictor of information-sharing behaviors (Table 3). Additionally, the adjusted mean, ranging from 0 (not at all likely to engage) to 1 (very likely to engage) for information- sharing behaviors among nurse practitioners/ registered nurses (0.617) was higher than that among physicians/physician assistants (0.562), with a mean difference of ±0.056. Qualitative Supplemental Table S1 presents selected quotes from participants regarding their cur- rent knowledge and the adverse health effects they believe are associated with nitrate con- tamination in drinking water. Themes that emerged from our analysis were uncertainty or a lack of knowledge, cancer, pregnancy and pediatric complications, other diseases and long-term effects, vague symptoms, and acute effects. Overall, the responses ranged from statements of a lack of concern or lack of knowledge to a desire for further education. Discussion In our study, the HCPs reported low knowl- edge of the health risks associated with nitrate contamination in drinking water. This lack of knowledge is likely due to minimal formal training or education on environ- mental nitrate exposures and the associ- ated adverse health outcomes. Consistent with this theory, our survey results showed that a limited number of HCPs had received any formal training or education about this important health topic. This lack of environ- mental health education and subsequent lack of HCP knowledge have resulted in low over- all self-confidence levels reported by HCPs when discussing nitrate contamination and associated health risks with patients.
Previous research has found that environ- mental health education for HCPs is largely lacking in the U.S. continuing education cur- riculum (Gehle et al., 2011; Roberts & Reigart, 2001; Tinney et al., 2015). Similar gaps in environmental health education have been identified in medical student training, with medical students rarely asking about paren- tal occupations for pediatric patients, which could increase the risk of other environmental exposures (Roberts & Reigart, 2001). Occupations in agriculture could present further environmental health risks for fami- lies who live in rural areas, who therefore might be at increased risk for developing can- cer (Carozza et al., 2008; Ward et al., 2018). Education in environmental health provides HCPs with the ability to recognize and pre- vent exposure-related illnesses, counsel patients on risks (e.g., water quality issues), and advocate for preventive interventions shown to reduce disease burden. Despite an overall lack of knowledge, education, and confidence, physicians/phy- sician assistants and nurse practitioners/ registered nurses appear highly open to improving their understanding of nitrates in drinking water. Studies show that physi- cian attitudes strongly influence whether or not they act on evidence: When physicians view an issue as low priority or irrelevant, they are less likely to counsel patients or adopt recommended practices (Cabana et al., 1999). Because attitude was the stron- gest predictor of information‑sharing in our study, interventions that specifically target HCP beliefs and perceived relevance could increase the likelihood that HCPs discuss nitrate risks with at‑risk patients, or poten- tially alter their approach. We believe that the findings about openness to behavior change and the likelihood of HCPs
to share educational materials with patients about nitrate contamination are the most important takeaways from our study, which suggests an opportunity for future education and training. Recent studies have assessed medical student preparedness to discuss envi- ronmental health with future patients and found a similar openness to engage in these conversations when provided with sufficient education and training (Garg & Mulloy, 2018; Kligler et al., 2021). These assessments among medical students are consistent with our find- ings, which showed that HCPs want to inform their patients about environmental exposure risks such as nitrate contamination, but that HCPs report lacking the environmental health education and knowledge to provide appropri- ate resources or counseling. Our study has several limitations. First, participants were a heterogeneous sample of HCP specialties, resulting in substantial variability in responses. Future studies could select specific specialties or stratify results by HCP specialty (e.g., pediatrics, general medicine). Second, no survey instrument existed prior to this research. Although the instrument developed here demonstrated good face, content, and construct valid- ity, no comparative survey was available to assess validity or reliability further. Third, although the sample size was sufficient for statistical analysis, the low response rate (1.8%) limits generalizability. The findings of our study have large impli- cations for multiple health sectors. In the U.S. to our knowledge, no studies have explored HCP perspectives related to knowledge, atti- tudes, and awareness about nitrate in drink- ing water sources. Further research should expand on our survey results by evaluating HCP perspectives in other agriculturally dominant areas across the U.S.
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Volume 89 • Number 3
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