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Environmental health literacy in support of social action: an environmental justice perspective.

Introduction

The unequal exposure to environmental hazards for residents in low-income and minority communities remains a major challenge to establishing safe and healthy communities. This is especially true for urban communities in the U.S. A national study examining environmental inequities found that almost one-third of low-income urban communities hosted hazardous waste facilities (Bullard, Mohai, Saha, & Wright, 2007). Another study concluded that families living in federally assisted public housing in metropolitan areas were at a greater risk for exposure to toxic releases of chemicals than more affluent communities (Cutter, Hodgson, & Dow, 2001). The vulnerability of these communities exacerbates environmental health disparities, thus leading to environmental injustice. Environmental injustice is the "unequal access to healthy and clean environments, including environmental amenities (Faber & Krieg, 2002)."

Effectively communicating environmental risks by using environmental health education can help protect communities disproportionately exposed to environmental hazards and address environmental injustice by increasing the awareness of hazardous exposures among community residents (Corburn, 2002; Hill, 2003; Sauve & Godmaire, 2004). Environmental health education integrates components of environmental, health, and risk education and supports health promotion, behavior change, and social action (Hill, 2003; Sauve & Godmaire, 2004). These education components are most effective when partnered with local knowledge (Corburn, 2002; Sauve & Godmaire, 2004).

Environmental health education programs are of little value if they do not promote health literacy (an understanding of health-related issues) that helps communities make informed choices to reduce hazardous exposure. Health literacy supports individuals in making informed decisions that can reduce health risks and ultimately increase their quality of life (Zarcadoolas, Pleasant, & Greer, 2005). Incorporating environmental information with health concepts can assist communities in achieving environmental justice through scientific, environmental, and civic literacy (Zarcadoolas et al., 2005). Civic literacy facilitates community awareness of public issues, e.g., environmental health issues, and promotes active participation in local decision-making processes. Therefore, environmental health literacy is a tool that can assist communities in achieving their environmental justice objectives.

This article summarizes the findings from a research effort that engaged public housing residents with environmental justice concerns in a Chicago community. This research project provides information for guiding the development of community-specific environmental health education materials. The aims of our study were to (1) understand community beliefs and knowledge of environmental health risks, (2) determine community levels of trust in federal/local agencies and community groups, and (3) identify strategies for mobilizing residents using environmental health messages and environmental health education programs.

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Methods

Community of Interest

This research study focused on residents of Altgeld Gardens and Phillip Murray Homes (herein referred to as "Altgeld"), a predominantly African-American public housing development in the Calumet industrial region (Riverdale Community Area) in Southeast Chicago, Illinois. Altgeld was built on top of an abandoned waste site and dozens of heavy manufacturing facilities and closed/active landfills surround the development (Figure 1). The Chicago Metropolitan Water Reclamation District sludge beds lie just north of Altgeld, and to the east are former and existing steel plants and an automotive assembly plant, which in 2010 released over 250,000 pounds of toxic chemicals and generated over 645,000 pounds of waste (Bouman, 2001; Right-to-Know Network, n.d.).

Many Altgeld residents are worried about their air and drinking water quality and the impacts of those on the rising infant mortality rate (IMR) and asthma rate (C. Johnson, personal communication, February 15, 2013). In 2000-2002, Riverdale had the highest IMR and low birth weight rates in Chicago (Illinois Department of Public Health, n.d.). IMR and low birth weight are related to toxic environmental exposure, especially traffic pollution (Kaiser et al., 2004; Morello-Frosch, Jesdale, Sadd, & Pastor, 2010). In addition, Altgeld's residential isolation in an industrial zone is exacerbated by a lack of access to fresh and nutritious food, which is essential to overall health promotion and protection. Residents fish in area ponds and grow vegetables in the soil, which raises concerns given the fact that area soil and water contain pollution. The ingestion of fish and vegetables in contact with that pollution can increase the cumulative toxicity of these substances in individuals exposed to these pollutants (Fox, 2002). This is especially notable since an area containing electrical transformers on Altgeld's property had contaminated soil from polychlorinated biphenyls (Adams, 2000).

Despite the multiple environmental and social challenges the community faces, Altgeld has a rich history of social support systems and community activism. Many residents with job skills and experience started training classes to educate fellow residents in different vocational areas to increase their competitiveness for available employment opportunities. Several resources are also available within the community, including a community center, a public park center, a community health clinic, and a church. Residents have also been involved in community activism as evidenced by the resident-led environmental justice organization, People for Community Recovery (PCR), which has been active in the Chicago area for over 30 years (C. Johnson, personal communication, February 15, 2013).

Research Study Design

This research study was conducted by the University of Minnesota's School of Public Health (the primary author was the principal investigator of this study) in collaboration with PCR. The U.S. Environmental Protection Agency's (U.S. EPA's) Office of Research and Development provided expertise for the poststudy analysis of the data and results. The research protocol for our study was approved and monitored by the institutional review board of the University of Minnesota.

Six focus groups were conducted with 42 adult residents (residing two years or more in Altgeld) at convenient community locations. Residents were asked nine questions that focused on their understanding and perceptions of environmental hazards, government agencies and community groups, and ways to address environmental problems (Table 1). Discussions were audio recorded for transcription. All focus group participants completed a brief survey to collect additional information to supplement the discussions. Survey questions were adapted from previous questionnaires (Byrd, VanDerslice, & Peterson, 1997, 2001). Respondent validation surveys were administered to an additional 48 residents to corroborate focus group findings; these additional residents did not participate in the focus groups (Cho & Trent, 2006). All study participants were compensated for their time through monetary incentives.

Data Analysis

A professional transcriptionist company transcribed focus group audio recordings. Using QSR NVivo qualitative data management software version 2.0, transcripts were deductively categorized and predominant themes and subthemes were identified across focus groups and cross-checked with the respondent validation surveys (Miles & Huberman, 1994). Descriptive statistics were generated for focus group and respondent validation survey data using SAS software version 9.2. Bivariate analyses were performed to determine differences between focus group and respondent validation participants; the level of statistical significance selected was p < .05.

Results

Demographic Characteristics

Each of the 90 study participants (focus group: 42 members; respondent validation: 48) were African-Americans ranging in age from 18 to 64 years old (focus group: mean age 45 years and median age 49 years; respondent validation: mean age 44.9 years and median age 47 years; Table 2). Most study participants were female (focus group: 62%; respondent validation: 68%). Demographic characteristics for validation survey respondents did not differ significantly from focus group participants by age (p = .88), gender (p = .54), education (p = .49), work situation (p = .09), and current marital status (p = .48).

Community-Perceived Environmental Health Risks

In the focus group survey, crime, drugs, the dumping of hazardous waste, and landfills were seen as posing the greatest risks to the community. Environmental health risks were not limited to just physical risks, but also included social risks such as crime and police brutality. One focus group member stated, "The risks in our environment have a lot of different categories besides dealing with the pollution in the air, in the soil, in the water. It's a risk just walking to your house." Concerns were also raised about adverse health effects that could possibly be linked to local environmental pollution: "If you looked at all the people who have been living out here who are dying from cancer, that's not a coincidence." Table 3 provides a detailed list of perceived environmental health risks.

Community-Trusted Sources of Environmental Health Information

The majority of focus group participants reported getting "a fair amount" to "a lot" of information about the environment from PCR (67%) and television programs (60%). Approximately 45% of focus group participants reported that friends/relatives were their primary source of environmental information. Government agencies were not a major source of information, as only 41%, 36%, and 31% of focus group participants reported receiving at least "a fair amount" of information from the U.S. EPA, the Illinois Department of Public Health, and the Chicago Department of Public Health, respectively. Focus group participants believed they received the least amount of environmental information from private industry. When discussing local water testing, one focus group member stated, "I can see the water pollution people. They take a sample of the water. They're testing it to see how much pollution is in the water, but we don't get no information about it. We don't get no feedback on the results."

Community Trust in Government

Many focus group participants did not believe federal/local agencies were adequately protecting their health, nor did they trust government agencies. One frustrated focus group participant stated, "We live in pollution ... [A past elected official] let us be in this [word deleted]. We have a [word deleted] factory over here. They're building all around the hill and we're living around it. Our water ... the smell ... comes through the sewage system. I was standing one time by the drain, they sent it through there and I damn near fainted. That stuff will kill you and we stand around. They [elected officials] let them send it out at certain times. They send it out at night when we are asleep. Do you know they're killing us?" Similar statements were recurring throughout focus group discussions.

Community-Focused Environmental Health Messages

Most focus group participants indicated they received most of their environmental health information from the resident-led organization, PCR, and friends/relatives. Focus group discussions emphasized building on existing communication channels when relaying health messages. They recommended creating a residential network with respected residents from the neighborhood who have been trained in environmental health issues. Once trained, these residents would educate other residents on community-specific risks and mitigation strategies. One focus group participant suggested the creation of resident-led committees: "We need to form subgroups or subcommittees ... and focus on certain areas where we want to gather information and become sort of experts ... doing research." Focus group participants believed residents were the best source of information because they communicated in a language that was understandable and knew the best ways to engage other residents. In addition, residents would be more receptive to community members when discussing community concerns.

Discussion

Our study provides a clearer understanding of one community's perceptions of environmental health risks, trust level of agencies, and specific strategies to develop and disseminate environmental health messages. Focus group discussions, as corroborated by respondent validation surveys with additional study participants, identified several community-specific environmental health concerns. In general, friends/relatives were focus group participants' primary and trusted source of environmental information. These participants also did not trust federal/local agencies, nor did they feel these agencies were protecting their community's health. Suggestions for community-specific environmental health messages were provided and included utilizing community members to disseminate health information.

Focus group discussions in this study reflect the findings from similar studies that examined community perceptions of environmental health risks to inform health education programs (Corburn, 2002; Evans, Fullilove, Green, & Levison, 2002; Green, Fullilove, Evans, & Shepard, 2002; Taylor-Clark, Koh, & Viswanath, 2007). As with similar studies, participants had a broader definition of environmental health risks, which incorporated risks from the physical and social environments. This broader definition must be considered when designing programs and tailoring health messages, especially for low-income communities with environmental justice concerns, as the purpose for tailored messages is to inform, raise awareness, and encourage residents to work for environmental justice in their communities. Furthermore, engaging community members in the identification of risks can ensure that health messages are both culturally and socially appropriate. When considering the fact that nearly 45% of the focus group members self-report their health status as fair or poor, it is imperative that community residents be fully included in development of environmental health assessments and associated education and outreach programs.

Focus group participants also believed that many of their concerns were not being addressed by local agencies, and that local officials stand idly by while pollution is generated and released into their community. This observation is indicative of the belief by some participants that they have been abandoned and ignored by the different levels of government when it comes to their health and physical well-being. Participants also expressed a low level of trust in government agencies and did not believe they were receiving enough information. If these agencies were to communicate health messages, residents would have a difficult time believing them and might reject the health messages. Some residents believe that their elected officials intentionally allow companies to poison their community. This level of distrust would make it difficult for any agency to effectively disseminate health information to residents.

While participants did not exhibit a great deal of trust towards agencies, they did cite PCR, the resident-led community organization, as a significant source of environmental health information. Participants stressed the importance of using local agencies, such as PCR, to communicate health messages because they have established trust relationships with community members. In addition, focus group participants identified friends and relatives as reliable sources of environmental health information. Several participants suggested creating a resident environmental health network. As residents, the trained advocates would be able to effectively engage other residents and to communicate with them in a socio-culturally appropriate way.

Utilizing a community health worker approach through a resident-focused network to communicate environmental health risks is a viable strategy to develop community-specific environmental health messages. Several studies have demonstrated the effectiveness of community health worker interventions in the reduction of environmental health risks, especially with low-income communities (Bryant-Stephens, Kurian, Guo, & Zhao, 2009; Krieger, Takaro, Song, & Weaver, 2005; Perez, Findley, Mejia, & Martinez, 2006). These interventions are especially effective at empowering communities to address social injustices, i.e., environmental injustice (Perez et al., 2006). Using a community-engaged research approach through the Centers for Disease Control and Prevention's Prevention Research Centers (PRCs) is another strategy to develop community-specific environmental health messages. Community-engaged research approaches can enhance trust between community members and academic institutions by incorporating community input to community-specific research efforts (Clinical and Translational Science Awards Community Engagement Key Function Committee, 2011). Research projects conducted at PRCs have improved health outcomes among low-income communities by tailoring interventions to meet community needs (Douyon, Chavez, Bunte, Horsburgh, & Strunin, 2010; Gustat, Rice, Parker, Becker, & Farley, 2012).

Conclusion

This research effort adds to existing evidence that low-income community members are interested in increasing their knowledge of the environmental risks and want to be actively involved in risk analysis and risk reduction efforts in their local area. The findings indicate that more applied research activity should be conducted using the results of our study. Follow-up research projects should be designed based on the outcome of this project and should focus on quantitative measures of the impact that increased health literacy can have on improved civic engagement (i.e., increased interaction with local political and industrial leaders on community issues), improved knowledge of environmental health risks, and improved community health outcomes (i.e., based on community-based and community-led health education programs). Resources should be directed towards an applied research effort working with a well-organized community partner like PCR to objectively measure the effect of improved awareness of environmental health risks.

Acknowledgements: This project would not have been possible without the contribution of residents of Altgeld Gardens-Murray Homes and staff/volunteers at PCR. The project was funded by the J.B. Hawley Research Award in the Division of Epidemiology & Community Health at the University of Minnesota's School of Public Health.

Disclaimer: The U.S. Environmental Protection Agency through its Office of Research and Development collaborated in the research described herein. It has been subjected to agency review and approved for publication. Mention of trade names or commercial products does not constitute endorsement or recommendation for use.

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Brandi M. White, MPH

Medical University of South Carolina

Eric S. Hall, MA, MCE

U.S. Environmental Protection Agency

Cheryl Johnson

People for Community Recovery

Corresponding Author: Brandi M. White, Medical University of South Carolina, 151 Rutledge Avenue, Charleston, SC 29425-1600. E-mail: whitbm@musc.edu.
TABLE 1

Focus Group Interview Questions/Comments

#    Question/Comment

1    What are environmental hazards?

2    What environmental health risks are present in your community?

3    How effective are government agencies in protecting your
     community's health?

4    How effective are environmental groups in protecting your
     community's health?

5    What do you do to protect your health from environmental
     health risks?

6    What should be done to address environmental problems in
     your community?

7    Describe how you can bring your community together to protect
     against environmental hazards.

8    Describe the type of information that would get your community
     to do something about environmental hazards.

9    Where would you like to get this information?

Participant Demographic Characteristics

                              Focus Group %   Respondent Validation %
                                (n = 42)             (n = 48)

Gender
   Male                            38                   32
   Female                          62                   68
Age
   Average, years                 45.09                44.90
   Median, years                   49                   47
Education
   High school graduate            48                   36
   Some college and beyond         31                   30
Employment status
   Unemployed                      36                   30
Current marital status
   Married                         12                   16
   Never been married              55                   36

TABLE 3

Community-Specific Perceived Environmental Health Risks

Category              Specific Risks

Poor air quality      Outdoor:
                      Near roadway pollutants (Interstate 94)
                      Industrial emissions
                      Odor (Metropolitan Water Reclamation)
                      Indoor:
                      Mold
                      Environmental tobacco smoke
                      Lead

Land contamination    Illegal dumping
                      Landfills (Land & Lakes landfills, CID Landfills
                      Note: CID Landfills are permitted to store
                      commercial hazardous wastes and are governed by
                      the Resource Conservation and Recovery Act [RCRA]
                      of 1976, as amended) Polychlorinated biphenyl
                      contamination Home gardens and soil contaminants

Environmentally       Infant mortality
related illnesses     Cancer
                      Asthma
                      Lupus

Poor water quality    Fish consumption advisories (Little
                      Calumet River)
                      Contaminated drinking water
                      Sewage overflow
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Title Annotation:ADVENCEMENT OF THE PRACTICE
Author:White, Brandi M.; Hall, Eric S.; Johnson, Cheryl
Publication:Journal of Environmental Health
Geographic Code:1USA
Date:Jul 1, 2014
Words:3796
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