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-
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October 2026 • Journal of Environmental Health
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