The outdoor air quality flag program in Central California: a school-based educational intervention to potentially help reduce children's exposure to environmental asthma triggers.Introduction Many factors influence children's exposure to biological and chemical pollutants pollutants see environmental pollution. , including known environmental asthma triggers, in microenvironments frequently inhabited during daily activities such as school (Shendell, Barnett, & Boese, 2004). Although microenvironments inside, in school classrooms, and outside, on playgrounds, may be quite different, it has been clearly demonstrated in the scientific literature that outdoor air influences indoor air and environmental quality Only outdoor air quality, however, is subject to local, state, and federal regulations. Therefore, community groups may focus more on outdoor air quality. An American Academy of Pediatrics The American Academy of Pediatrics ("AAP") is an organization of pediatricians, physicians trained to deal with the medical care of infants, children, and adolescents. Its motto is: "Dedicated to the Health of All Children. (AAP AAP - Association of American Publishers ) report has emphasized the need to limit children's exposure to outdoor air pollution because of many known and suspected adverse health effects, including asthma (AAP, 2004). Environmental factors influence the prevalence and severity of asthma, and likely help cause asthma (U.S. Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979 Health and Human Services, HHS , 2006). In addition, numerous federal reports on environmental threats to children's health Children's Health Definition Children's health encompasses the physical, mental, emotional, and social well-being of children from infancy through adolescence. have called for improved risk communication and environmental education (U.S. Environmental Protection Agency Environmental Protection Agency (EPA), independent agency of the U.S. government, with headquarters in Washington, D.C. It was established in 1970 to reduce and control air and water pollution, noise pollution, and radiation and to ensure the safe handling and [U.S. EPA EPA eicosapentaenoic acid. EPA abbr. eicosapentaenoic acid EPA, n.pr See acid, eicosapentaenoic. EPA, n. ], 1996, 2000, 2002). Recommendations for preventing or reducing exposure to such environmental hazards 'Environmental hazard' is a generic term for any situation or state of events which poses a threat to the surrounding environment. This term incorporates topics like pollution and Natural Hazards such as storms and earthquakes. must inherently be based on the best available science (Shendell, Barnett, & Boese, 2004). For example, the most current outdoor air quality data could be clearly summarized and delivered to targeted stakeholders Stakeholders All parties that have an interest, financial or otherwise, in a firm-stockholders, creditors, bondholders, employees, customers, management, the community, and the government. . This paper describes a novel school-based, visual environmental public health educational intervention intended to help reduce the exposure of children--and adults--to outdoor air pollution, including known environmental asthma triggers like ozone and particles. The overarching o·ver·arch·ing adj. 1. Forming an arch overhead or above: overarching branches. 2. Extending over or throughout: "I am not sure whether the missing ingredient . . . goal was to enhance the learning, recreational, and work environments of students and staff. The specific purpose of the intervention, the Asthma-Friendly Outdoor (Ambient Surrounding. For example, ambient temperature and humidity are atmospheric conditions that exist at the moment. See ambient lighting. ) Air Quality Flag Program, was to establish an education and communication tool so that Central California Central California can refer to one of several divisions or regions of the U.S state of California:
1. permanently change local policy with respect to existing operating procedures in school districts and schools to help reduce the exposure of students, teachers, staff, and nearby communities to outdoor environmental asthma triggers and 2. provide education on air quality and potential health effects from exposure to air pollutants. Background Demographics The attributes of people in a particular geographic area. Used for marketing purposes, population, ethnic origins, religion, spoken language, income and age range are examples of demographic data. The San Joaquin Valley Noun 1. San Joaquin Valley - a vast valley in central California known for its rich farmland Calif., California, Golden State, CA - a state in the western United States on the Pacific; the 3rd largest state; known for earthquakes agricultural region of Central California comprises urban and rural communities in nine counties: Fresno, Kern Kern, river, 155 mi (249 km) long, rising in the S Sierra Nevada Mts., E Calif., and flowing south, then southwest to a reservoir in the extreme southern part of the San Joaquin valley. The river has Isabella Dam as its chief facility. , Kings, Madera, Mariposa, Merced, San Joaquin San Joaquin (săn wäkēn`), river, c.320 mi (510 km) long, rising in the Sierra Nevada, E Calif., and flowing W then N through the S Central Valley to form a large delta with the Sacramento River near Suisun Bay, an arm of San Francisco Bay. , Stanislaus, and Tulare. Populations living in these communities were potentially exposed to some of the worst outdoor air quality in the nation, particularly to ozone and particles (American Lung Association The American Lung Association (ALA) is a non-profit organization that "fights lung disease in all its forms, with special emphasis on asthma, tobacco control and environmental health". , 2006). The populations are diverse in terms of socioeconomics, race/ethnicity, culture, immigration immigration, entrance of a person (an alien) into a new country for the purpose of establishing permanent residence. Motives for immigration, like those for migration generally, are often economic, although religious or political factors may be very important. status, and primary languages spoken at home. Community Action to Fight Asthma Initiative The mission of the first Community Action to Fight Asthma (CAFA CAFA Class Action Fairness Act of 2005 (US) CAFA Community Action to Fight Asthma CAFA Canadian Association of Farm Advisors (Winnipeg, Manitoba, Canada) CAFA Confederation of Alberta Faculty Associations ) Initiative (2002-2005) was to reduce the prevalence of asthma and the exposure to environmental hazards among California's school-aged children with asthma. CAFA synergized the advocacy, outreach, education, and intervention work of 12 local asthma coalitions (LCs) that had funding for their various activities--and 20 other LCs and environmental health and justice groups--across the state, linking them through four Regional Centers and a State Coordinating Office. CAFA's structure and its technical-assistance partners in policy advocacy, media, and evaluation augmented the capacity of the LCs from a previous focus on improving access to clinical asthma care and management quality to the pursuit of advocacy to affect environmental policy change at local, regional, and state levels. Using strategic-planning processes, each LC selected an area or areas of focus for local advocacy. The focus of CAFA LCs and the regional center in central California was outdoor air pollution, especially ozone and particles, the latter including both pollens and diesel exhaust. The Intervention The outdoor air quality flag program intervention was based on the ambient air quality index (AQI AQI Air Quality Index AQI Al-Qaeda in Iraq AQI Agricultural Quarantine Inspection AQI Australian Questioning Intonation (aka upspeak or high rising terminal) AQI Al-Qaeda Intelligence AQi Intelligent Acoustic Quantification ) used by the local air pollution control district, the San Joaquin Valley Air Pollution Control District (SJVAPCD SJVAPCD San Joaquin Valley Air Pollution Control District (California) ) (http://www.valleyair.org/aqinfo/forecast.htm), the California Air Resources Board California Air Resources Board (CARB) is the "clean air agency" of the state of California in the United States. Established originally in 1967, it is a part of the California Environmental Protection Agency, an organization which reports directly to the California (CARB) (http://www.arb arb See arbitrageur. .ca.gov), and U.S. EPA (http://www.epa.gov/airnow/aqi.html) (U.S. EPA, 2003). SJVAPCD information was based on data collected from government outdoor air quality monitoring sites throughout the region. These data were then incorporated into technical modeling software with data on meteorology meteorology, branch of science that deals with the atmosphere of a planet, particularly that of the earth, the most important application of which is the analysis and prediction of weather. , topography topography (təpŏg`rəfē), description or representation of the features and configuration of land surfaces. Topographic maps use symbols and coloring, with particular attention given to the shape and elevations of terrain. , pollution sources, and consideration of season or time of year to produce daily forecasts. The AQI focused on two monitored outdoor air pollutants, ozone and particulate matter particulate matter n. Abbr. PM Material suspended in the air in the form of minute solid particles or liquid droplets, especially when considered as an atmospheric pollutant. Noun 1. (coarse particles, or [PM.sub.10], and fine particles Fine particles are an air pollutant mainly produced by cars running on diesel. Other sources are the combustion of fossil fuels in power plants and various industrial processes. , or [PM.sub.2.5]). Measured ambient levels of these criteria pollutants can be compared to federal and state standards for defined time periods (CARB, 2006). In general, levels of ozone are of relatively more concern during summer months, and particles are of relatively more concern during the late fall and winter, when there are fewer hours of sunlight (less ozone formed) and an increased chance for atmospheric inversions that trap cold air closer to the ground and limit dispersion dispersion, in chemistry dispersion, in chemistry, mixture in which fine particles of one substance are scattered throughout another substance. A dispersion is classed as a suspension, colloid, or solution. and dilution of pollutants such as particles. For participating schools and other community locations, AQI information was sent, according to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. preference, by fax or e-mail from SJVAPCD to a designated staff member who had volunteered (a secretary, a custodian bailee (custodian) n. a person with whom some article is left, usually pursuant to a contract (called a "contract of bailment"), who is responsible for the safe return of the article to the owner when the contract is fulfilled. , a teacher, a nurse, etc). The AQI was the best estimated forecast for the following day. The appropriately colored flag was raised each morning, underneath both the American and state of California flags (see photo above). The flag system, based on the AQI defined and referenced above, used colors to code air quality, as follows: * Green flag: Air quality is good (AQI 0-50) -- no restriction for outdoor activities. * Yellow flag: Air quality is moderate (AQI 51-100) -- people with severe asthma or respiratory diseases Noun 1. respiratory disease - a disease affecting the respiratory system respiratory disorder, respiratory illness adult respiratory distress syndrome, ARDS, wet lung, white lung - acute lung injury characterized by coughing and rales; inflammation of the should limit outdoor activity time and avoid activities based on prolonged pro·long tr.v. pro·longed, pro·long·ing, pro·longs 1. To lengthen in duration; protract. 2. To lengthen in extent. exertion exertion, n vigorous action, a great effort, a strong influence. . * Orange flag: Air quality is unhealthy for sensitive groups (AQI 101-150) -- outdoor activities should be minimized, and the majority of activity time replaced with indoor physical activity or health education according to the following suggestions: [ILLUSTRATION OMITTED] -- April-October -- limit outdoor physical activity in the afternoon (i.e., hold activities in the morning if possible) because of higher levels of ozone, particles, or both; -- November-March -- limit outdoor physical activity in the morning (i.e., hold activities in the afternoon when possible) because of higher levels of airborne particles and colder air. * Red flag: Air quality is unhealthy (AQI 151-200) -- avoid outdoor physical activities (i.e., physical education and recess should be held indoors in a multipurpose mul·ti·pur·pose adj. Designed or used for several purposes: a multipurpose room; multipurpose software. multipurpose Adjective room or gym or, if not possible because of space or time constraints In law, time constraints are placed on certain actions and filings in the interest of speedy justice, and additionally to prevent the evasion of the ends of justice by waiting until a matter is moot. , health education should be conducted). Schools and locations were recruited to participate in the outdoor air quality flag program by LC members, including volunteers and CAFA employees. Since the program was provided free to participating schools and because financial and human resources The fancy word for "people." The human resources department within an organization, years ago known as the "personnel department," manages the administrative aspects of the employees. were limited, in some counties schools expressing initial interest were screened on the basis of selection criteria. If these criteria were met, then typically the school was included in the program. The criteria included, but were not limited to, the following factors: * commitment to the project by the school district and the principal; * proximity to outdoor-air-quality monitoring stations and historically poor outdoor air quality in the county and community; * presence of rural, under-served populations for whom environmental justice concerns might apply; and, * the population of the county relative to that of the region. Specifically, schools and locations were recruited with personal visits, letters to county superintendents of education, and countywide communications to principals, science teachers, and nurses. Schools participating in the outdoor air quality flag program intervention received the necessary resources for free, including colored flags; age and culturally-appropriate educational materials in several languages (including English, Portuguese, Spanish, and Hmong); and, informational presentations for teachers and staff as well as for students and parents. Initial Progress, 2004-2006 Table 1 summarizes process data on the initial success of recruitment for and implementation of this intervention in locations where CAFA LCs and the American Lung Association of Central California have been active. The data, by school year, are presented for newly participating public schools and private schools, school districts, and other community locations. The term "other community locations" refers to one or more of the following in each county: local hospitals, health clinics, environmental health departments, daycare facilities, school district offices, and universities. If the intervention was initiated at an "other location" between two school years, then we included it in the data for the upcoming school year. Overall, with resources acquired through the 2005-2006 school year, hundreds of schools in dozens of school districts and over 20 other community locations participated (Table 1). This effort was driven by the LCs, with volunteers and limited resources provided through CAFA, not by an environmental epidemiology/exposure assessment study of air quality and respiratory health risks. Therefore, rich impact and outcome data were neither planned nor eventually available. Limited initial short-term impact data were, however, available for two counties, Merced and Tulare, based on a school survey (n = 77) conducted in 2004, which informed their CAFA evaluation reports (unpublished report provided by Philliber Research Associates, part of the CAFA-1 evaluation team funded by the California Endowment). Selected results highlighted this intervention's potential value: * 90 percent stated that the intervention was easy to administer. * 86 percent stated that their schools provided alternatives to more strenuous stren·u·ous adj. 1. Requiring great effort, energy, or exertion: a strenuous task. 2. Vigorously active; energetic or zealous. exercise outdoors, schedule modifications for student activities, or both, on poor-air-quality days (orange or red flags). * About four out of five respondents stated that the colored flags made teachers and staff more aware of the relationships between air quality and children's health, and made everyone more aware of poor-air-quality days (ozone or particles) in their community or region. * Quotes from school officials and parents included the following: "Parents are grateful for the air quality flag program.... It is very easy to use, simple,... and easy to implement." Summary of Experiences with Intervention to Date Our process and limited impact data and experiences from winter 2004 through spring 2006 suggested that the outdoor air quality flag program, as a simple, visual environmental-education intervention designed to help reduce the exposure of children, adult employees, and especially people with asthma to known outdoor air environmental asthma triggers, had the potential to contribute positively to local and regional environmental public health and to encourage asthma-conscious school policy formulation. According to estimates provided during the 2004 surveys with program participants, this intervention has been ongoing (as of 2005-2006) for several years at school campuses with over 53,000 students, teachers, and staff, as well as at other community locations with over 1,200 employees in Merced County, and over 33,800 teachers, students, and staff and 2,200 employees at other locations in Tulare County. In addition, the confidence that resulted from the initial success of the intervention encouraged LCs to start work on other school interventions, like low-allergy planting and implementing U.S. EPA's IAQ IAQ Indoor Air Quality IAQ Investment Administration Qualification IAQ Infrequently Asked Questions IAQ Internal Air Quality IAQ Inuit Art Quarterly IAQ Illinois Air Quality Tools for Schools Program in Tulare County. The price of this intervention program has proven to date to be relatively low. The cost, which declines depending on the quantity purchased at one time, was approximately $64 to $104 per school per set of four colored flags. This cost estimate excluded staff time--if volunteers were not used--for technical assistance and travel to school sites. It also excluded support (received in-kind) for printing of educational materials and training presentation slides for parents, students, and staff. The outdoor air quality flags program may help, by increasing awareness, knowledge, and behavior changes Behavior change refers to any transformation or modification of human behavior. Such changes can occur intentionally, through behavior modification, without intention, or change rapidly in situations of mental illness. , to reduce environmental exposures for tens of thousands of children in participating school districts in each county in which it has been implemented in central and southern California--and now also in other states (e.g., in Maricopa County, Arizona Maricopa /ˌmɛ.ɹəˈko.pə/ County is located in the central part of the U.S. state of Arizona. , and Cleveland County, North Carolina Cleveland County is a county located in the U.S. state of North Carolina. As of 2000, the population was 96,287. Its county seat is Shelby6. History The county was formed as Cleveland County in 1841 from parts of Lincoln County and Rutherford County. ). To date, the following important lessons have been learned: 1. Science-based, simple, visual, low-cost school-based educational interventions to help reduce human exposure to outdoor environmental asthma triggers (ozone, particles, and pollens) can work in socio-economically and ethnically diverse urban and rural or agricultural communities. 2. Local health and environmental justice groups like asthma coalitions can successfully lead school-based environmental interventions to help improve children's quality of life. Acknowledgements: The project described in this report received funding, in-kind support, or both from the California Endowment, the American Lung Association of Central California, Mercy Medical Center Merced Foundation, the Tulare District Health Care System, the San Joaquin Valley Air Pollution Control District, Bank of the Sierra, Fresno Regional Foundation, and the California Breathing project (funded through a cooperative agreement between the U.S. Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. and the California Department of Health Services-Environmental Health Investigations Branch). Corresponding Author: Derek G. Shendell, Assistant Professor, Institute of Public Health, Georgia State University History Georgia State University was founded in 1913 as the Georgia School of Technology's "School of Commerce." The school focused on what was called "the new science of business. , 140 Decatur Street Decatur Street can refer to:
REFERENCES American Academy of Pediatrics Committee on Environmental Health. (2004). Ambient air pollution: Health hazards health hazard Occupational safety Any agent or activity posing a potential hazard to health. Cf Physical hazard. to children. Pediatrics, 114(6), 1699-1707. American Lung Association. (2006). State of the air report: 2006. Retrieved September 12, 2006, from http://lungaction.org/reports/sota06_full.html. California Air Resources Board. (2006). Federal and state standards for criteria outdoor air pollutants. Retrieved May 30, 2006, from http://www.arb.ca.gov/aqs/aaqs2.pdf. Shendell, D.G., Barnett, C., & Boese, S. (2004). Science-based recommendations to prevent or reduce potential exposures to biological, chemical, and physical agents in schools. Journal of School Health, 74(10), 390-396. U.S. Environmental Protection Agency, Office of the Administrator. (September 1996). Environmental health threats to children (EPA 175-F-96-001). Washington, DC, Author. U.S. Environmental Protection Agency, Office of Research and Development. (October 2000). Strategy for research on environmental risks to children (EPA/600/R-00/068). Washington, DC: Author. U.S. Environmental Protection Agency, Office of Research and Development. (September 2002). Asthma research strategy (EPA 600/R-01/061). Washington, DC: Author. U.S. Environmental Protection Agency (August 2003). Air quality index--A guide to air quality and your health (EPA-454/K-03-002). Retrieved May 30, 2006, from http://www.epa.gov/airnow/aqibroch/. U.S. Department of Health and Human Services. (2006). The health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General--Executive summary. Retrieved September 12, 2006, from http://www.cdc.gov/tobacco/sgr/sgr_2006/index.htm. Derek G. Shendell, D.Env., M.P.H. Mary-Michal Rawling Christine Foster, R.R.T. Alicia Bohlke Bobbie Edwards Susie A. Rico Justina Felix Sandra Eaton Stephanie Moen, R.R.T., R.C.P. Eric M. Roberts, M.D., Ph.D. Mary Beth Love, Ph.D., M.S.
TABLE 1 Numbers of School Districts, Schools, and Other Locations
Implementing the Outdoor Air Quality Flags Program
2003-2004
Number of New Public Number Number of Other
School Year School Districts; of Private Locations With
Location Number of New Schools Schools Flags (a,b)
Merced-Mariposa 4; 11 0 4
(Merced_County
only (c))
Tulare County 0; 0 0 0
Fresno County -- (e) -- (e) -- (e)
Kings County -- (e) -- (e) -- (e)
Madera County -- (e) -- (e) -- (e)
San Joaquin -- (e) -- (e) -- (e)
County
Stanislaus -- (e) -- (e) -- (e)
County
Total for school 4; 11 0 4
year
Overall (cumulative total) = over 36 public school districts, 402 public
schools, 22 private schools, and 22 other locations.
2004-2005
Number of New
Public School Number Number of Other
School Year Districts; Number of Private Locations With
Location of New Schools Schools Flags (a,b)
Merced-Mariposa 18; 70 (d) 8 7
(Merced_County
only (c))
Tulare County 5; 57 0 3
Fresno County 2; 40 0 0
Kings County 1; 4 0 0
Madera County 1; 3 0 0
San Joaquin 1; 8 0 0
County
Stanislaus -- (e) -- (e) -- (e)
County
Total for school 28; 123 8 10
year
Overall (cumulative total) = over 36 public school districts, 402 public
schools, 22 private schools, and 22 other locations.
2005-2006
Number of New
Public School Number Number of Other
School Year Districts; Number of Private Locations With
Location of New Schools Schools Flags (a,b)
Merced-Mariposa 0; 80 11 7
(Merced_County
only (c))
Tulare County 3; 29 2 1
Fresno County 0; 100 0 0
Kings County 0; 10 0 0
Madera County 0; 8 0 0
San Joaquin 0; 15 0 0
County
Stanislaus 1; 33 1 0
County
Total for school 4; 267 14 8
year
Overall (cumulative total) = over 36 public school districts, 402 public
schools, 22 private schools, and 22 other locations.
(a) Other locations were local hospitals, health clinics, environmental
health departments, daycare facilities, school district offices, and
universities (for example, University of California-Merced).
(b) If a program was initiated at "other locations" between two school
years, then it was counted in the data for the upcoming school year.
(c) Mariposa County was not included because it is not in the San
Joaquin Valley Air Pollution Control District. Also, please note that
data for Kern County for the 2004-2006 school years were not available
from the local asthma coalition.
(d) At one elementary school and one high school, outdoor air quality
flags are flying at two locations on the school grounds.
(e) Implementation of the program had not yet started.
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