NEHA April 2023 Journal of Environmental Health

The April 2023 issue of the Journal of Environmental Health (Volume 85, Number 8), published by the National Environmental Health Association.

JOURNAL OF Environmental Health Dedicated to the advancement of the environmental health professional

Volume 85, No. 8 April 2023

www. neha.org

Published by the National Environmental Health Association

JOURNAL OF Environmental Health Dedicated to the advancement of the environmental health professional $3091* 3 46.0

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ABOUT THE COVER

Communicating Results of Drinking Water Tests From Private Wells: Designing Report-Back Materials to Facilitate Understanding.................................................... 8 Decreased Moderate to Vigorous Physical Activity Levels in Children With Asthma Are Associated With Increased Trac-Related Air Pollutants................................................... 16

More than 42.5 million people in the U.S. rely on private wells for household water use. This month’s cover article, “Communicating Results of Drinking Water Tests From

ADVANCEMENT OF THE PRACTICE

Guest Commentary: Bacterial Contamination in Long Island Sound: Using Preemptive Beach Closure to Protect Public Health ........................................................................................ 26 Programs Accredited by the National Environmental Health Science and Protection Accreditation Council....................................................................................... 29

Private Wells: Designing Report-Back Materials to Facilitate Understanding,” assessed the eec- tiveness of graphic-based (i.e., pictorial) report- back materials in communicating the presence of toxic metals in private well water and soil samples. It also explored associations between recommendations in the report-back materials and appropriate actions to protect health taken by a subset of participants in an environmental monitoring pilot study. The results suggest that a simple pictorial format, in combination with more detailed supporting text, can be useful in highlighting results that require action. See page 8. Cover image © iStockphoto: eggeeggjiew

Building Capacity: Trusting Email to Build Capacity .................................................................. 30

Direct From ATSDR: Exposure Investigations Conducted by the Agency for Toxic Substances and Disease Registry ........................................................................................ 32 Direct From CDC/Environmental Health Services: Connecting Environmental Public Health With the Revised 10 Essential Public Health Services ............................................. 36

The Practitioner’s Tool Kit: Practical Field Sampling Strategies ................................................. 40

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Environmental Health Calendar ...............................................................................................42

ADVERTISERS INDEX

Resource Corner........................................................................................................................ 43

Accela ................................................................... 51 Awards and Scholarships............................ 5, 15, 25 Environmental Health and Land Reuse Certificate Program ..............................................35 HS GovTech.......................................................... 52 Inspect2GO Environmental Health Software......... 2 JEH Advertising ....................................................14 NEHA Credentials.............................. 24, 31, 35, 39 NEHA Endowment and Scholarship Funds..... 7, 38 NEHA Membership .......................................... 4, 49

YOUR ASSOCIATION

President’s Message: An Opportunity to Educate the Public, Policy Makers, and Other Professionals ............................................................................................................................ 6

In Memoriam............................................................................................................................. 39

Special Listing ........................................................................................................................... 44

NEHA 2023 AEC....................................................................................................................... 46

NEHA News .............................................................................................................................. 48

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in the next Journal of Environmental Health don’t miss h A Call for Action to Increase the Scrutiny of Surface Cleaning and Cleaning Agents in Retail Food Establishments h Federal Meat and Poultry Inspection Duties and Requirements—Part 1: History and Current Responsibilities h Increasing Diversity in Environmental Health Graduate Programs h Lead Source Attribution by Stable Isotope Analysis in Child Risk Assessment Investigations

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Published monthly (except bimonthly in January/February and July/ August) by the National Environmental Health Association, 720 S. Colorado Blvd., Suite 105A, Denver, CO 80246-1910. Phone: (303) 802- 2200; Fax: (303) 691-9490; Internet: www.neha.org. E-mail: kruby@ neha.org. Volume 85, Number 8. Yearly subscription rates in U.S.: $150 (electronic), $160 (print), and $185 (electronic and print). Yearly international subscription rates: $150 (electronic), $200 (print), and $225 (electronic and print). Single copies: $15, if available. Reprint and advertising rates available at www.neha.org/jeh. Claims must be filed within 30 days domestic, 90 days foreign, © Copyright 2023, National Environmental Health Association (no refunds). All rights reserved. Contents may be reproduced only with permission of the managing editor. Opinions and conclusions expressed in articles, columns, and other contributions are those of the authors only and do not reflect the policies or views of NEHA. NEHA and the Journal of Environmental Health are not liable or responsible for the accuracy of, or actions taken on the basis of, any information stated herein. NEHA and the Journal of Environmental Health reserve the right to reject any advertising copy. Advertisers and their agencies will assume liability for the content of all advertisements printed and also assume responsibility for any claims arising therefrom against the publisher. The Journal of Environmental Health is indexed by Clarivate, EBSCO (Applied Science & Technology Index), Elsevier (Current Awareness in Biological Sciences), Gale Cengage, and ProQuest. The Journal of Environmental Health is archived by JSTOR (www.jstor.org/journal/ jenviheal). All technical manuscripts submitted for publication are subject to peer review. Contact the managing editor for Instructions for Authors, or visit www.neha.org/jeh. To submit a manuscript, visit http://jeh.msubmit.net. Direct all questions to Kristen Ruby-Cisneros, managing editor, kruby@neha.org. Periodicals postage paid at Denver, Colorado, and additional mailing offices. POSTMASTER: Send address changes to Journal of Environmental Health , 720 S. Colorado Blvd., Suite 105A, Denver, CO 80246-1910.

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Volume 85 • Number 8

Walter S. Mangold Award

extraordinary adjective ex·traor·di·nary | ikˈstrôrd(ə)nˌerē 1. Going beyond what is usual, regular, or customary 2. Exceptional to a marked extent

Walter S. Mangold dedicated his life to the practice of environmental health in an extraordinary and exemplary way. In doing so, he became a beacon of excellence and inspiration for all environmental health pro- fessionals who followed after him. Do you have a colleague who fits the defini - tion of doing extraordinary environmental health work? Consider taking the time to nominate them for the Walter S. Mangold Award, our most prestigious award. Nomination Deadline: May 15, 2023 neha.org/mangold-award

Honoring a history of advancing environmental health. Walter F. Snyder was a pioneer in our field and was the cofounder and first executive director of NSF. He embodied outstanding accomplishments, notable contributions, demonstrated capacity, and leadership within environmental health. Do you know someone like that? Nominate them for the Walter F. Snyder Award for outstanding contributions to the advancement of environmental health. This award is cosponsored by NSF and NEHA. Nomination Deadline: May 1, 2023 neha.org/awards nsf.org/about-nsf/annual-awards Walter F. Snyder Award

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YOUR ASSOCIATION

 PRESIDENT’S MESSAGE

An Opportunity to Educate the Public, Policy Makers, and Other Professionals

D. Gary Brown, DrPH, CIH, RS, DAAS

A s I mentioned in a previous column, environmental health professionals were the founders of the American Public Health Association. Most people do not realize that environmental health profes- sionals were key personnel at the start of the Centers for Disease Control and Prevention (CDC) on July 1, 1946, helping to fulfill the primary mission of CDC to prevent malaria from spreading across the nation. Environ- mental health professionals helped start Earth Day. Every year on April 22, Earth Day marks the anniversary of the birth of the modern en- vironmental movement in 1970, which arose out of pollution aecting our health. The Earth Day website states, “Until this point, mainstream America remained largely oblivi- ous to environmental concerns and how a pol- luted environment threatens human health.” The first Earth Day had 10% of the U.S. population participating from all politi- cal parties, walks of life, and communities throughout the land. People were participat- ing to improve the health of people in the U.S. through a reduction in pollution. The early 1970s saw the creation of the U.S. Environ- mental Protection Agency and Occupational Safety and Health Act. In addition, numerous environmental laws were passed, including the National Environmental Education Act; Clean Air Act; Clean Water Act; Endangered Species Act; and Federal Insecticide, Fungi- cide, and Rodenticide Act. Earth Day went global with the first World Environment Day on June 5, 1973, led by the United Nations Environment Program. This year marks the 50th anniversary of World

As environmental health professionals, we need to let our policy makers, fellow pro- fessionals, and the public know the impact pollution has on health. Air pollution causes approximately 7 million premature deaths every year. Single-use plastics make up 70% of marine litter. The CDC Waterborne Dis- ease & Outbreak Surveillance Reporting website (www.cdc.gov/healthywater/surveil lance/burden/findings.html) estimates that 17 waterborne pathogens caused 7.15 million illnesses, 601,000 emergency department visits, 118,000 hospitalizations, and 6,630 deaths in 2014. Further, CDC estimates each year that 1 in 44 people gets sick from water- borne diseases in the U.S. The Marketing Rule of 7 states a person needs to hear a message at least 7 times before they will take action. This rule was developed by the movie industry in the 1930s when stu- dio executives discovered a certain amount of advertising was required to compel someone to see one of their movies. Regardless of a magic number of times for people to hear a message, everyone agrees messages are more eective when repeated. As we all know, not all messages are created equally. We have the wonderful advantage that environmental health messages are meaning- ful and impactful since they aect health, something near and dear to everyone’s heart. The varied stories of our profession can cre- ate an emotional connection. Unlike many professions, we touch all aspects of life hav- ing thousands of jobs performed by environ- mental health professionals. How many other professions can claim their members work in

We have the wonderful advantage that environmental

health messages are meaningful and impactful.

Environment Day, which has grown into a global platform for raising environmen- tal awareness and spurring environmental action. Millions of people from 150 countries have taken part in World Environment Days, helping drive change along with motivat- ing national and international environmen- tal policy. Each World Environment Day is hosted by a dierent country and the ocial celebrations focus on a particular theme. The 2023 campaign is #BeatPlasticPollution, hosted by Côte d’Ivoire, and focuses on sus- tainable solutions to plastic pollution. International days and weeks are a power- ful advocacy tool that provides an occasion to educate the public, policy makers, and other professionals. As stated in my September col- umn, I am asking you to assist by becoming like the Whos—shouting from the roof tops the words people must hear far and near—by talking to folks outside our sphere, especially the younger generations about this wonder- ful, magical career.

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national parks, cruise ships, amusement parks, laboratories, water and wastewater treatment, disaster management, education, and restau- rants for the armed services, nonprofits, gov- ernment agencies, and industry in the U.S. We are a storybook with never-ending stories that involve all genres including action, adventure, detective work, mystery, science, inspiration, hope, changing lives, and communities. What environmental health professionals need to improve on is spreading the message. When I speak with environmental health professionals throughout the county, they all passionately talk about environmental health since they care about our profession, which is much more powerful than talking about

things we are ambivalent about. The more environmental health professionals we have spreading the word, the better because people listen more closely to people they care about or are in their community. The National Environmental Health Association is devel- oping messages you can add to your tool kit to spread the word about this wonderful, wild world of environmental health. We all know the more positive contact you have with your audience, the better your message will be not only received but also ingrained in people’s heads. Think of the slogans for Nike (Just Do It) and Wheaties (Breakfast of Champions)—when you hear these slogan you know the brand. One of our

slogans could be “Environmental Health: The Profession Changing the World.” As Aristotle said, “There can be no words without images.” Good storytellers make emo- tional connections. We have the stories, images, and storytellers to share this wonderful, wild world of environmental health. As Jimmy Cli sang in One More , “I got one more story to tell; Mystery, my story; I got one more story to tell; True story, my glory; One more, one more, one more, one more.” Please help spread the envi- ronmental health word day and night by shar- ing your story with everyone in sight.

gary.brown@eku.edu

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April 2023 • Journal of Environmental Health

$" " SCIENCE

Communicating Results of Drinking Water Tests From Private Wells: Designing Report-Back Materials to Facilitate Understanding

ciently to take appropriate action can still be a challenge (Chappells et al., 2014; Jones et al., 2006; Kreutzwiser et al., 2011). Increasingly, the reporting of sampling results to study participants is viewed as contributing to the development of environ- mental health literacy, which enables par- ticipants to make health-protective decisions (Brody et al., 2014; Gray, 2018; Morris et al., 2016; Severtson et al., 2006). Understanding well test results prepares participants to take steps to reduce harmful exposures (Ramirez- Andreotta et al., 2016), though awareness alone is not sucient for exposure reduction (Zheng & Flanagan, 2017). Within this context, the Well Empowered pilot study was conducted in North Caro- lina, a state where approximately 2.4 million people (25% of residents) access their drink- ing water from private wells (Dieter et al., 2018). Toxic metals from industry-derived and naturally occurring contamination have been identified in private wells across North Carolina (Sanders et al., 2012; Vengosh et al., 2016). After learning about the presence of such metals in local wells, residents in Stokes County reached out to the Univer- sity of North Carolina at Chapel Hill Super- Sarah Yelton, MS Institute for the Environment, University of North Carolina at Chapel Hill Andrew George, PhD Institute for the Environment, University of North Carolina at Chapel Hill Martha Scott Tomlinson, PhD Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill Paige A. Bommarito, PhD Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill Rebecca C. Fry, PhD Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill Kathleen M. Gray, MSPH, PhD Institute for the Environment, University of North Carolina at Chapel Hill

'786&(8 This evaluation assessed the eectiveness of graphic- based (i.e., pictorial) report-back materials in communicating the presence of toxic metals in private well water and soil samples. It also explored associations between recommendations in the report-back materials and appropriate actions to protect health taken by a subset of participants in an environmental monitoring pilot study. Overall, 39 residents of Stokes County, North Carolina, participated in the Well Empowered pilot study, which included water and soil testing and analysis. All participants received materials explaining the extent to which toxic metals were present in their well water and soil. A subset of participants ( n = 14) responded to a follow- up evaluation, which showed that many found at least one component of their test results “very easy to understand.” The existence of a federal standard for comparison appeared to influence participant recall of results, which was more accurate for contaminants with a federal maximum contaminant level. Our evaluation results suggest that a simple pictorial format, in combination with more detailed supporting text, can be useful in highlighting results that require action.

Introduction More than 42.5 million people in the U.S. rely on private wells for household water use (Dieter et al., 2018); over 20% of those wells contain one or more contaminants at concentrations exceeding health-based stan- dards (DeSimone et al., 2009). Yet no ongo- ing monitoring of private wells is required, meaning well users are responsible for test- ing wells and remediating contamination. Without testing, residents using private wells for drinking water could be unaware of con-

tamination. Barriers to testing include cost, convenience, and optimism bias (Fox et al., 2016; Zheng & Flanagan, 2017). Addition- ally, well users rely on sensory cues (e.g., taste, smell, discoloration) to determine if water is safe to drink, despite many contami- nants not being detectable by such cues (Fla- nagan et al., 2015; Jones et al., 2006). The promise of obtaining personal results about drinking water quality might incentivize par- ticipation in well testing studies (Segev et al., 2021), but understanding the results su-

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FIGURE 1

Example of the Pictorial Format Used to Present Results to Study Participants of Well Water Testing for Toxic Metals

Metals in Your Water

Arsenic

Cadmium

Vanadium

0.05 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Hexavalent Chromium

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0

10 15 20 25 30 35 40 45 50

18.93

14.75

1.29

1.26

10.00

0 5

5.00

0.07

0.30

0.11

0.07

Your kitchen tap and well water exceed the EPA maximum contaminant level for arsenic in drinking water.

Your kitchen tap and well water exceed the NC 2L groundwater quality interim maximum for vanadium in drinking water.

Legend

Your Kitchen Tap Water

Your Well

EPA Maximum Contaminant Level

NC 2L Groundwater Interim Maximum Allowable Concentration NC DHHS Health Screening Level

Well Empowered Research Study | UNC Superfund Research Program | 2017

Note. DHHS = Department of Health and Human Services; EPA = Environmental Protection Agency; NC = North Carolina; UNC = University of North Carolina.

fund Research Program (SRP), to help them identify potential exposures and associated health risks. SRP researchers collaborated with residents to address their concerns and develop strategies to reduce exposure (Tom- linson et al., 2019). This collaboration was informed by previous e orts to share results from exposure studies in ways that build environmental health literacy (Boronow et al., 2017; Ramirez-Andreotta et al., 2016). As part of this pilot study, a subset of par-

ticipants joined an evaluation focused on: 1) the e ectiveness of using pictorial materi- als to report well water and soil test results to study participants and 2) whether such communications were associated with recall of test results or subsequent health-protec- tive actions. Methods Participants in the Well Empowered pilot study ( N = 39) were invited to participate in a

follow-up evaluation to provide feedback on report-back materials provided by the study. All Well Empowered participants completed a survey documenting their usage of well water, previous well testing, and where relevant, understanding of prior test results. The sam- pling process has been described elsewhere (Tomlinson et al., 2019) and the study was deemed exempt by the Institutional Review Board of the University of North Carolina at Chapel Hill (IRB# 16-1721).

April 2023 • Journal of Environmental Health

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FIGURE 2

Example of the Pictorial Format Used to Present Results to Study Participants of Soil Testing for Toxic Metals

Metals in Your Soil

All results are presented in milligrams per kilogram (mg/kg).

Arsenic

Cadmium

Lead

Manganese

0 10 20 30 40 50 60 70 80 90 100

1 , 000 1 , 200 1 , 400 1 , 600 1 , 800 2 , 000

1,900

1,600

0 200 400 600 800

166

Your Soil Compared to EPA Regional Screening Levels Any results with a gr a y background are considered to be above the federal screening level for that contaminant. Contaminant Screening Level Your Soil Arsenic 40 92 Cadmium 78 0 Lead 1 , 600 166 Manganese 1 , 900 21

Legend

Your Soil EPA Regional Screening Level

Well Empowered Research Study | UNC Superfund Research Program | 2017 Note . All soil sample analysis was conducted at the EPA National Exposure Research Laboratory.

Note. EPA = Environmental Protection Agency; UNC = University of North Carolina.

In response to concerns about local indus- trial contamination, approximately one half of Well Empowered participants (49%, n = 19) had previously tested their wells for met- als and a subset indicated they did not under- stand prior results that were provided in a text or table format by local agencies, state agencies, or private laboratories. These par- ticipants found results “confusing” or noted that they “didn’t know how to read it.” In the Well Empowered study, partici- pants received printed report-back materials

explaining the extent to which toxic met- als were present in samples. Based on some participants’ prior experiences of confusion, the research team aimed to develop materials that were understandable and could inform appropriate health-protective actions. Each packet contained: • Pictorial results showing exceedances of rel- evant federal maximum contaminant levels (MCLs), secondary MCLs, treatment tech- niques, or state groundwater standards or health screening levels (Figures 1 and 2).

• Table of complete results for each water and soil sample. • Fact sheets that explained health risks of exposure to contaminants that exceeded standards or guidelines. • Definitions of terms that included dierent types of standards and guidelines. Packets were distributed at a community presentation where aggregated results were shared with study participants and other residents (Figure 3). Research team members met individually with participants to explain

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of the results packet using a Likert scale from very easy to very dicult and 2) perceived helpfulness of additional materials that were provided (e.g., contaminant fact sheets, defi- nitions of terms). Residents also were asked to recall any exceedances in their well tests and if they had taken action in response to well test results. If the residents responded armatively, they were asked to describe the action(s) taken. Results Of the participants in the Well Empowered pilot study, 14 returned a complete evalua- tion survey and all had exceedances of some type. These respondents were representative of the larger pilot study sample in terms of demographics. Most respondents were White, self-identified as male, were >65 years, had at least some college education, and earned >$40,000 annually. Approximately 80% lived at their current residence for >10 years. Approximately 50% had not tested their wells in the 2 years prior. Evaluation survey responses suggested that respondents found pictorial results and tabular results easy to understand. For water test results, 11 respondents rated their understanding of the two formats: 9 (82%) indicated that the pictorial results were “very easy to understand” and 7 (64%) indicated the table format was “very easy to understand.” For soil test results, 9 respon- dents rated their understanding of the two formats, with 100% ( n = 9) indicating that the pictorial results were “very easy to understand” and 7 (78%) indicating that the table format was “very easy to understand.” Approximately 93% of respondents rated the supplementary materials (i.e., defini- tions of terms and contaminant fact sheets for exceedances) as “very helpful.” A total of 9 respondents attended the com- munity meeting, along with approximately 20 other residents, and most respondents (89%) described the community presenta- tion as “very easy to understand.” During the community meeting, participants asked questions of the research team, with a sub- set of questions focused on how to interpret exceedances of state health screening levels or the state groundwater standard. Attend- ees also sought guidance in determining what actions they should take based on their results.

FIGURE 3

Example of a Slide Used During a Community Meeting to Present Community-Wide Well Water Test Results for a Single Contaminant

Arsenic Community Summary (39 samples) Range: 0.01–25.51 ppb

= Do notdrink your water!

EPA MCL 10 ppb

Note. EPA = Environmental Protection Agency; MCL = maximum contaminant level.

FIGURE 4

Recalled Versus Actual Exceedances of Federal and State Standards in Well Empowered Test Results

State Standard

Federal Standard

Actual Exceedances

R ecalled Exceedances

results as needed. Residents who were unable to attend the meeting received their results via mail, with interpretation support from the project team as needed.

Within 90 days of packet distribution, an evaluation survey was sent to each partici- pant. Respondents were asked to describe 1) their ease in understanding each component

April 2023 • Journal of Environmental Health

ADVANCEMENT OF THE SCIENCE

Even though respondents found results easy to understand, most could not correctly recall all exceedances in their results, with only two respondents accurately recalling all exceedances. Notably, respondents had a more accurate recall of exceedances of federal standards for well water or soil when com- pared with exceedances of state standards (73% versus 45%, respectively; Figure 4). Among respondents who answered the question about follow-up action ( n = 13), three took appropriate actions based on exceedances in their results (e.g., replaced pipes, shared results with doctor, installed filters). The well and soil results of these three respondents showed exceedances of at least one federal standard. Several respon- dents reported that they were still consider- ing water filter installation. One respondent, who was drinking bottled water, indicated cost as a barrier to taking permanent action to reduce exposure to contamination. Discussion In the Well Empowered study, results pre- sented pictorially, together with tables and information about health eects, were designed to support well users in taking or considering appropriate actions. Yet in fol- low-up surveys, many could not recall all the contaminants that were present in their water. An inability to recall specific contami- nants in well water or soil could limit the ability of residents to follow up appropri- ately, including implementing proper filtra- tion methods or sharing information with a healthcare professional. Existence of federal standards (such as MCLs) might have played a role in recall, as respondents typically could recall results for contaminants that exceeded a federal standard. The federal standards were repre- sented as a bright red line in pictorial for- mat, signifying danger, which also could have influenced respondents’ attention to those contaminants. In contrast, multiple state standards were used as benchmarks for other contaminants in the Well Empow- ered pilot study, including established and interim groundwater quality standards and health screening goals. In report-back mate- rials, the state standards were represented pictorially with different colors of lines (orange or purple) depending on the type of standard (groundwater standard versus

FIGURE 5

Adapted Version of Well Empowered Test Results

Your Well Results – Metals and Your Health All results below are presented in parts per billion ( ppb ), which is equal to micrograms per liter ( μg/l ). Any results with an orange background are considered to be above the relevant standard. Contaminants are grouped under the relevant federal or state standard that regulates their presence in drinking water. Potential health effects are noted for any contaminants that exceed standards and for lead, which has no known safe level of exposure. Potential Health Effects Federal Drinking Water Quality Standard (U.S. EPA Maximum Contaminant Level or Treatment Technique (TT) Action Level) Antimony 6 0.36 Arsenic 10 10.89 Skin damage, circulatory system problems, and risk of cancer. Cadmium 5 0.04 Copper 1300 (TT) 12,748 Liver or kidney damage; gastrointestinal distress. Contaminant Standard Your Water

There is no safe level of lead in water 1 . Infants and children: delays in physical or mental development. Adults: Kidney problems, high blood pressure, and increased risk of cancer.

Lead

15 (TT)

2.45

Selenium

0.05

Uranium

0.32

1 US Environmental Protection Agency set a Maximum Contaminant Level Goal (MCLG) for lead at zero based on the best available science which shows there is no safe level of exposure to lead.

Note: All sample analysis was completed at the UNC Superfund Research Program Chemistry and Analytical Core Laboratory.

Note. UNC = University of North Carolina; U.S. EPA = U.S. Environmental Protection Agency.

health screening goal, respectively). These variations in color also could have influ- enced participants’ perceptions of associated danger and recall. Further, emerging con- taminants, such as vanadium and hexavalent chromium, might not have been as familiar to participants, which could have influenced their ability to recall them. These results highlight challenges associ- ated with communicating information on emerging contaminants, specifically the lack of relevant standards and limited or lack- ing information on potential health eects. Without an established reference point, resi- dents might be less able to identify and take appropriate health-protective action. This finding is supported by questions raised in the community meeting about what actions, if any, residents should take based on test results when exceedances were not based on a federal standard. Ultimately, such decisions are up to the individual and grounded in the

resources available to them and the amount of risk they are willing to accept. When discussing potential actions, the research team communicated risks in a con- text of uncertainty related to potential health eects of contaminants that were not well studied. Given that expert views of risk often dier from lay public views (Frewer, 2004; Johnson & Slovic, 1998), researchers who share environmental exposure data with com- munities could benefit from training in princi- ples of risk and science communication. Such training could prepare researchers to engage in dialogue with residents who are seeking to understand potential health implications and then implement health-protective actions. Since completing this evaluation in Stokes County, North Carolina, the study team has collected evaluation surveys from over 250 participants in the Well Empowered study and we are currently analyzing these data for similar trends. Individual report-back

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materials have been adapted to provide results in table format (Figure 5), though we continue to use pictorial representations to share aggregated data in community meet- ings, where educators and scientists are available to interpret pictures and respond to risk-related questions. This evaluation also informed the development of tools to understand environmental health literacy associated with toxic metal contamination of groundwater (Gray et al., 2021), with resident feedback informing the next itera- tion of pictorial representations of well test results. Other recent studies have high- lighted the value of using visual communi- cation tools to build trust, accurately com- municate health risk, and support people in taking appropriate health-protective actions (Machida et al., 2022; Tomsho et al., 2019). Taken together, these studies underscore the importance of iterative processes to refine report-back materials in response to assess- ments of participant engagement, under- standing, and subsequent action. The limitations of the Well Empowered pilot study apply to this evaluation as well, in

particular, the small sample size and the rela- tive homogeneity of the study sample. While the 14 evaluation respondents were represen- tative of the larger pilot study sample, they were not necessarily representative of the pop- ulation of well owners in the region or state. Additionally, participation in the study was voluntary and residents of the study commu- nity had been exposed to local media coverage about well water contamination issues during the study time frame, and this exposure could have influenced their responses. Conclusion The results of this evaluation underscore the value of incorporating pictorial representa- tions when communicating technical infor- mation about well water contamination, especially to highlight results that require action and in combination with detailed information in other formats. This evalua- tion also suggests that established health- based standards might serve as important benchmarks for comparison of analytical results. Going forward, repeated cycles of assessment and refinement will provide

insight into the most eective use of visual communications during the report-back process. Acknowledgements: The study team acknowl- edges the support of our community partner on this project, Appalachian Voices, for assist- ing us in developing and implementing the sampling protocol and aiding us in connecting with community members. Many thanks to the study participants for giving us access to their homes and sharing samples of their water and soil for analysis. This work was supported by the National Institute of Environmental Health Sciences (Grant Numbers: P42-ES005948, P42-ES031007, P30-ES010126). The funder was not involved in study design, implemen- tation, or publication. Corresponding Author: Sarah Yelton, Envi- ronmental Education and Citizen Science Program Manager, Center for Public Engage- ment With Science, Institute for the Environ- ment, University of North Carolina at Chapel Hill, CB 1105, Chapel Hill, NC 27599-1105. Email: sarah.yelton@unc.edu.

References

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$" " SCIENCE

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ADVANCEMENT OF THE SCIENCE

Abstract People with asthma, particularly young children, are more adversely affected by traffic emissions—and regular exercise reduces asthma symptoms and improves lung function. We studied the relationship between air pollution and objectively measured physical activity in children with asthma who were attending a school near a freeway. We continuously monitored air pollutants—PM 2.5 , PM 10 , nitrogen dioxide (NO 2 ), and ozone (O 3 )—at the school for 10 weeks and measured physical activity levels via accelerometry in children ( n = 12, ages 6–12 years). Concentrations of PM 2.5 , PM 10 , and NO 2 were negatively associated with moderate to vigorous physi- cal activity (PM 2.5 and PM 10 : p < .001; NO 2 : p = .04) and positively associated with sedentary activity (PM 2.5 and PM 10 : p < .001; NO 2 : p = .02). Physical activity is decreased and sedentary behavior is increased in children with asthma when air pollutants are higher. Strategies are available to mitigate air pollutant impact on beneficial physical activity during the school day. Decreased Moderate to Vigorous Physical Activity Levels in Children With Asthma Are Associated With Increased Traffic-Related Air Pollutants

Children attending elementary school spend 6–8 hr/day in school microenvironments that commonly also include outdoor activities. In many countries, severe conditions of air pollution frequently require the cancellation of physical or sport activities in elementary schools, which could lead to an increase in sedentary behavior (Giles & Koehle, 2014). This occurrence is particularly relevant for schools located near busy traffic intersec- tions or freeways where children might be exposed to higher levels of air pollution from traffic. Coarse particulate matter (PM 10 or particles <10 µm in aerodynamic diameter), fine particulate matter (PM 2.5 or particles <2.5 µm in aerodynamic diameter), nitrogen dioxide (NO 2 ), and ozone (O 3 ) are some of the traffic-related air pollutants to which children of roadside communities are com- monly exposed. Center for Community Health Impact, University of Texas Health Science Center School of Public Health Juan Aguilera, MPH, MD, PhD Center for Community Health Impact, University of Texas Health Science Center School of Public Health Soyoung Jeon, PhD Department of Economics, Applied Statistics, and International Business, New Mexico State University Amit U. Raysoni, MPH, PhD School of Earth, Environmental, and Marine Sciences, The University of Texas Rio Grande Valley Wen-Whai Li, PhD Department of Civil Engineering, The University of Texas at El Paso Leah D. Whigham, PhD, FTOS

Introduction

& Koehle, 2014). In controlled studies, the exposure to air pollutants during exercise has led to a reduction in performance (Rundell et al., 2008) and inhalation of airborne particles during exercise has been associated with a reduction in lung function (Cutrufello et al., 2012). Increased levels of air pollutants have also been associated with self-reported inac- tivity (Roberts et al., 2014; Wen et al., 2009). For these reasons, exposure to an environ- ment with an increased level of air pollution might lead to adverse health effects due to airway exposure to airborne pollutants from increased respiratory intake and also lack of physical activity.

Exposure to Air Pollutants and Physical Activity

Physical activity is essential for overall health (Janssen & LeBlanc, 2010). Regular outdoor activities, such as walking or jogging, can lead to a significantly lower risk of cardio- vascular disease and metabolic syndrome (Chen et al., 2013). Outdoor physical activ- ity, however, also exposes people to air pollut- ants that can lead to adverse health problems such as cardiovascular diseases (Le Tertre et al., 2002; Sharman et al., 2004), respiratory diseases (Pope et al., 2009; Shah et al., 2013), diabetes (Bowe et al., 2018), and obesity (An et al., 2018). During physical activity, a higher deposi- tion of air pollutants in the lungs can occur due to increased respiratory intake (Giles

Physical Activity in People With Asthma

People with asthma might engage in fewer aerobic activities and less physical activity overall due to concerns of triggering asthma symptoms (Garfinkel et al., 1992; Mälkiä & Impivaara, 1998). Given that asthma affects children at a young age when they are likely to establish their health habits, it is impor- tant to emphasize physical activity with pediatric asthma patients (Mancuso et al., 2006). National management guidelines for asthma state that most people’s symptoms

Air Pollutants in the School Environment

Spending time in an environment near heavy traffic is particularly harmful to children.

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