NEHA April 2023 Journal of Environmental Health

JOURNAL OF fifteen dollars Environmental Health Published by the National Environmental Health Association Dedicated to the advancement of the environmental health professional Volume 85, No. 8 April 2023

April 2023 • 3962&0 3+ 2:.6321*28&0 *&08- 3 ADVANCEMENT OF THE SCIENCE 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 Tra€c-Related Air Pollutants................................................... 16 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 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 ADVANCEMENT OF THE PRACTITIONER Environmental Health Calendar ...............................................................................................42 Resource Corner........................................................................................................................ 43 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 JOURNAL OF Environmental Health Dedicated to the advancement of the environmental health professional $3091* 3 46.0 ABOUT THE COVER 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 Private Wells: Designing Report-Back Materials to Facilitate Understanding,” assessed the ešectiveness of graphic-based (i.e., pictorial) reportback 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 ADVERTISERS INDEX 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

4 Volume 85 • Number 8 in the next Journal of Environmental Health don’t miss Official Publication Journal of Environmental Health (ISSN 0022-0892) Kristen Ruby-Cisneros, Managing Editor Ellen Kuwana, MS, Copy Editor Hughes design|communications, Design/Production Cognition Studio, Cover Artwork Soni Fink, Advertising For advertising call (303) 802-2139 Technical Editors William A. Adler, MPH, RS Retired (Minnesota Department of Health), Rochester, MN Gary Erbeck, MPH Retired (County of San Diego Department of Environmental Health), San Diego, CA Thomas H. Hatfield, DrPH, REHS, DAAS California State University, Northridge, CA Dhitinut Ratnapradipa, PhD, MCHES Creighton University, Omaha, NE 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) 8022200; Fax: (303) 691-9490; Internet: E-mail: kruby@ 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 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 theJournal 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 ( jenviheal). All technical manuscripts submitted for publication are subject to peer review. Contact the managing editor for Instructions for Authors, or visit To submit a manuscript, visit Direct all questions to Kristen Ruby-Cisneros, managing editor, 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. Printed on recycled paper. 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 Join our environmental health community. It is the only community of people who truly understand what it means to do what you do every day to protect the health of our communities. Join us today. Your people are waiting. Find Your People. Find Your Training. Find Your Resources.

April 2023 • 3962&0 3+ 2:.6321*28&0 *&08- 5 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 professionals who followed after him. Do you have a colleague who fits the definition 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 Walter S. Mangold Award extraordinaryadjective ex·traor·di·nary | ikˈstrôrd(ə)nˌerē 1. Going beyond what is usual, regular, or customary 2. Exceptional to a marked extent 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 Walter F. Snyder Award

6 $3091* • 91'*6 YOUR ASSOCIATION D. Gary Brown, DrPH, CIH, RS, DAAS An Opportunity to Educate the Public, Policy Makers, and Other Professionals  PRESIDENT’S MESSAGE As 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 professionals 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. Environmental health professionals helped start Earth Day. Every year on April 22, Earth Day marks the anniversary of the birth of the modern environmental movement in 1970, which arose out of pollution aˆecting our health. The Earth Day website states, “Until this point, mainstream America remained largely oblivious to environmental concerns and how a polluted environment threatens human health.” The first Earth Day had 10% of the U.S. population participating from all political parties, walks of life, and communities throughout the land. People were participating 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. Environmental 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, Fungicide, 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 Environment Day, which has grown into a global platform for raising environmental awareness and spurring environmental action. Millions of people from 150 countries have taken part in World Environment Days, helping drive change along with motivating national and international environmental policy. Each World Environment Day is hosted by a diˆerent country and the ošcial celebrations focus on a particular theme. The 2023 campaign is #BeatPlasticPollution, hosted by Côte d’Ivoire, and focuses on sustainable solutions to plastic pollution. International days and weeks are a powerful advocacy tool that provides an occasion to educate the public, policy makers, and other professionals. As stated in my September column, 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 wonderful, magical career. As environmental health professionals, we need to let our policy makers, fellow professionals, 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 Disease & Outbreak Surveillance Reporting website ( 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 waterborne 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 studio 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 eˆective when repeated. As we all know, not all messages are created equally. We have the wonderful advantage that environmental health messages are meaningful and impactful since they aˆect health, something near and dear to everyone’s heart. The varied stories of our profession can create an emotional connection. Unlike many professions, we touch all aspects of life having thousands of jobs performed by environmental 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.

April 2023 • Journal of Environmental Health 7 national parks, cruise ships, amusement parks, laboratories, water and wastewater treatment, disaster management, education, and restaurants for the armed services, nonprofits, government 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 developing 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 emotional connections. We have the stories, images, and storytellers to share this wonderful, wild world of environmental health. As Jimmy CliŒ sang inOne 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 environmental health word day and night by sharing your story with everyone in sight. Make your contribution to the practice at SUPPORT THE NEHA ENDOWMENT FOUNDATION Our Endowment Foundation was created to allow us to do more for the environmental health profession than our annual budget might allow. Donations are used for the sole purpose of advancing the profession and its practitioners. Thank you to our donors! This list represents all donations made to the Endowment Foundation in the last 12 months as of press time. It does not include amounts pledged. DELEGATE CLUB ($1–$99) Thomas Abbott Erick Aguilar Tunde M. Akinmoladun Mary A. Allen Drake Amundson Logan Blank Glenn W. Bryant Ronald Bucci Kimberley Carlton Deborah Carpenter Richard W. Clark Alan S. Crawford Natasha Crawford Bonnie Czander Daniel de la Rosa Phyllis Dickens Theresa Dunkley-Verhage Gery M. DuParc Mina Emamy Wendy L. Fanaselle Krista T. Ferry Mary K. Franks Debra Freeman Keith Frey Monica Garcia Raymond E. Glos Keenan Glover Cynthia L. Goldstein Dolores Gough Monica V. Grezzi Karen Gulley Dianne Harvell Catherine Hefferin Steven Hernandez Michelle Holshue Scott E. Holmes Maria Ingram Kurt Johnson Margo C. Jones Samuel J. Jorgensen Leila Judd Samuel O. Kembi Anna E. Khan Theodore J. Koenig Richard Lavin Matthew A. Lindsey Jaime N. Lundblad Patricia Mahoney Patrick J. Maloney Joseph W. Matthews Ralph M Matthews Pamela Mefferd Derek Monthei Lisa Maggie Morehouse Ericka Murphy Sylvester Ndimele Johany D. Negron Bird Daniel B. Oerther Christopher B. Olson Jeffrey A. Priebe Michael K. Pyle Jeremiah Ramos Leejay Robles Luis O. Rodriguez Edyins Rodriguez Millan Kerry E. Rupp-Etling Anthony Sawyer Taylor J. Sawyer Marilou O. Scroggs Anton Shufutinsky Tonia W. Taylor William Toscano Marilyn C. Underwood Kendra Vieira Jessica Walzer Jeffrey A. Wangsao James M. White HONORARY MEMBERS CLUB ($100–$499) Kenneth C. Danielson Michele DiMaggio Ana Ebbert Carolyn J. Gray Michael G. Halko Donna K. Heran Gwendolyn R. Johnson Soheila Khaila Robert W. Landry Philip Leger Sandra M. Long Ann M. Loree James C. Mack Robert A. Maglievaz John A. Marcello Wendell A. Moore Victoria A. Murray Larry A. Ramdin Jacqueline L. Reszetar Michéle Samarya-Timm Mario Seminara Dorothy A. Soranno Linda Van Houten Lisa Whitlock 21st CENTURY CLUB ($500–$999) D. Gary Brown T. Stephen Jones Bette J. Packer Leon F. Vinci SUSTAINING MEMBERS CLUB ($1,000–$2,499) James J. Balsamo, Jr. Thomas J. Butts Brian K. Collins George A. Morris Peter M. Schmitt James M. Speckhart Ned Therien AFFILIATES CLUB ($2,500–$4,999) David T. Dyjack EXECUTIVE CLUB AND ABOVE (>$5,000) Vincent J. Radke

8 $3091* • 91'*6 $ " " SCIENCE 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 standards (DeSimone et al., 2009). Yet no ongoing monitoring of private wells is required, meaning well users are responsible for testing wells and remediating contamination. Without testing, residents using private wells for drinking water could be unaware of contamination. Barriers to testing include cost, convenience, and optimism bias (Fox et al., 2016; Zheng & Flanagan, 2017). Additionally, well users rely on sensory cues (e.g., taste, smell, discoloration) to determine if water is safe to drink, despite many contaminants not being detectable by such cues (Flanagan et al., 2015; Jones et al., 2006). The promise of obtaining personal results about drinking water quality might incentivize participation in well testing studies (Segev et al., 2021), but understanding the results su”- 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 environmental health literacy, which enables participants 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 (RamirezAndreotta et al., 2016), though awareness alone is not su”cient for exposure reduction (Zheng & Flanagan, 2017). Within this context, the Well Empowered pilot study was conducted in North Carolina, a state where approximately 2.4 million people (25% of residents) access their drinking 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 University of North Carolina at Chapel Hill Super- '786&(8 This evaluation assessed the e ectiveness of graphicbased (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 followup 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. 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 Communicating Results of Drinking Water Tests From Private Wells: Designing Report-Back Materials to Facilitate Understanding

April 2023 • Journal of Environmental Health 9 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 (Tomlinson 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 participants joined an evaluation focused on: 1) the e ectiveness of using pictorial materials 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-protective 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 sampling 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). Example of the Pictorial Format Used to Present Results to Study Participants of Well Water Testing for Toxic Metals Note. DHHS = Department of Health and Human Services; EPA = Environmental Protection Agency; NC = North Carolina; UNC = University of North Carolina. Metals in Your Water Well Empowered Research Study | UNC Superfund Research Program | 2017 Your Kitchen Tap Water Your Well EPA Maximum Contaminant Level NC 2L Groundwater Interim Maximum Allowable Concentration NC DHHS Health Screening Level 10.00 14.75 18.93 0 5 10 15 20 25 30 35 40 45 50 Concentration, parts per billion (ppb) Arsenic 5.00 0.11 0.07 0 5 10 15 20 25 30 35 40 45 50 Concentration, parts per Cillion (ppb) Cadmium 0.07 0.05 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Concentration, parts per billion (ppb) Hexavalent Chromium Your kitchen tap and well water exceedthe EPA maximum contaminant level for arsenicin drinking water. Your kitchen tap and well water exceedthe NC 2L groundwater quality interim maximum for vanadiumin drinking water. Legend 0.30 1.26 1.29 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 Concentration, parts per billion (ppb) Vanadium FIGURE 1

10 Volume 85 • Number 8 ADVANCEMENT OF THE SCIENCE In response to concerns about local industrial contamination, approximately one half of Well Empowered participants (49%, n = 19) had previously tested their wells for metals and a subset indicated they did not understand prior results that were provided in a text or table format by local agencies, state agencies, or private laboratories. These participants found results “confusing” or noted that they “didn’t know how to read it.” In the Well Empowered study, participants received printed report-back materials explaining the extent to which toxic metals 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 relevant federal maximum contaminant levels (MCLs), secondary MCLs, treatment techniques, 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 di’erent 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 Example of the Pictorial Format Used to Present Results to Study Participants of Soil Testing for Toxic Metals Note. EPA = Environmental Protection Agency; UNC = University of North Carolina. Metals in Your Soil Well Empowered Research Study | UNC Superfund Research Program | 2017 Note. All soil sample analysis was conducted at the EPA National Exposure Research Laboratory. Your Soil Compared to EPA Regional Screening Levels Any results with a gray 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 1,900 21 0 200 400 600 800 1,000 1,200 1,400 1,600 1,800 2,000 Concentration, mg/kg Manganese 1,600 166 0 200 400 600 800 1,000 1,200 1,400 1,600 1,800 2,000 Concentration, mg/kg Lead 78 0 0 10 20 30 40 50 60 70 80 90 100 Concentration, mg/kg Cadmium 40 92 0 10 20 30 40 50 60 70 80 90 100 Concentration, mg/kg Arsenic All results are presented in milligrams per kilogram (mg/kg). FIGURE 2

April 2023 • Journal of Environmental Health 11 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 participant. Respondents were asked to describe 1) their ease in understanding each component of the results packet using a Likert scale from very easy to very dicult and 2) perceived helpfulness of additional materials that were provided (e.g., contaminant fact sheets, definitions 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 armatively, they were asked to describe the action(s) taken. Results Of the participants in the Well Empowered pilot study, 14 returned a complete evaluation 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 respondents 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., definitions of terms and contaminant fact sheets for exceedances) as “very helpful.” A total of 9 respondents attended the community meeting, along with approximately 20 other residents, and most respondents (89%) described the community presentation as “very easy to understand.” During the community meeting, participants asked questions of the research team, with a subset of questions focused on how to interpret exceedances of state health screening levels or the state groundwater standard. Attendees also sought guidance in determining what actions they should take based on their results. Example of a Slide Used During a Community Meeting to Present Community-Wide Well Water Test Results for a Single Contaminant Note. EPA = Environmental Protection Agency; MCL = maximum contaminant level. Recalled Versus Actual Exceedances of Federal and State Standards in Well Empowered Test Results Arsenic Community Summary (39 samples) Range: 0.01–25.51 ppb 0 5 10 15 20 25 30 35 40 45 50 Concentration, parts per billion (ppb) EPA MCL 10 ppb = Do notdrink your water! 5 9 7 21 0 5 10 15 20 25 Federal Standard # of E x c eedan c es R ecalled Exceedances State Standard Actual Exceedances FIGURE 3 FIGURE 4

12 Volume 85 • Number 8 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 compared 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 respondents reported that they were still considering 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 presented pictorially, together with tables and information about health eŠects, were designed to support well users in taking or considering appropriate actions. Yet in follow-up surveys, many could not recall all the contaminants that were present in their water. An inability to recall specific contaminants in well water or soil could limit the ability of residents to follow up appropriately, including implementing proper filtration 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 represented as a bright red line in pictorial format, 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 Empowered pilot study, including established and interim groundwater quality standards and health screening goals. In report-back materials, the state standards were represented pictorially with different colors of lines (orange or purple) depending on the type of standard (groundwater standard versus health screening goal, respectively). These variations in color also could have influenced participants’ perceptions of associated danger and recall. Further, emerging contaminants, 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 associated with communicating information on emerging contaminants, specifically the lack of relevant standards and limited or lacking information on potential health eŠects. Without an established reference point, residents 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 context of uncertainty related to potential health eŠects of contaminants that were not well studied. Given that expert views of risk often diŠer from lay public views (Frewer, 2004; Johnson & Slovic, 1998), researchers who share environmental exposure data with communities could benefit from training in principles 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 Adapted Version of Well Empowered Test Results Note. UNC = University of North Carolina; U.S. EPA = U.S. Environmental Protection Agency. 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. 1US Environmental Protection Agencyset 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. Contaminant Standard Your Water 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. Lead 15 (TT) 2.45 There is no safe level of lead in water1. Infants and children: delays in physical or mental development. Adults: Kidney problems, high blood pressure, and increased risk of cancer. Selenium 50 0.05 Uranium 30 0.32 FIGURE 5

April 2023 • 3962&0 3+ 2:.6321*28&0 *&08- 13 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 meetings, 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 iteration of pictorial representations of well test results. Other recent studies have highlighted the value of using visual communication tools to build trust, accurately communicate 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 assessments of participant engagement, understanding, 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 relative homogeneity of the study sample. While the 14 evaluation respondents were representative of the larger pilot study sample, they were not necessarily representative of the population of well owners in the region or state. Additionally, participation in the study was voluntary and residents of the study community 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 representations when communicating technical information about well water contamination, especially to highlight results that require action and in combination with detailed information in other formats. This evaluation also suggests that established healthbased 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 eŠective use of visual communications during the report-back process. Acknowledgements: The study team acknowledges the support of our community partner on this project, Appalachian Voices, for assisting 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, implementation, or publication. Corresponding Author: Sarah Yelton, Environmental Education and Citizen Science Program Manager, Center for Public Engagement With Science, Institute for the Environment, University of North Carolina at Chapel Hill, CB 1105, Chapel Hill, NC 27599-1105. Email: Boronow, K.E., Susmann, H.P., Gajos, K.Z., Rudel, R.A., Arnold, K.C., Brown, P., Morello-Frosch, R., Havas, L., & Brody, J.G. (2017). DERBI: A digital method to help researchers oŠer “rightto-know” personal exposure results. Environmental Health Perspectives, 125(2), A27–A33. Brody, J.G., Dunagan, S.C., Morello-Frosch, R., Brown, P., Patton, S., & Rudel, R.A. (2014). Reporting individual results for biomonitoring and environmental exposures: Lessons learned from environmental communication case studies. 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14 $3091* • 91'*6 $ " " SCIENCE Johnson, B.B., & Slovic, P. (1998). Lay views on uncertainty in environmental health risk assessment. Journal of Risk Research, 1(4), 261–279. Jones, A.Q., Dewey, C.E., Doré, K., Majowicz, S.E., McEwen, S.A., Waltner-Toews, D., Mathews, E., Carr, D.J., & Henson, S.J. (2006). Public perceptions of drinking water: A postal survey of residents with private water supplies. BMC Public Health, 6, Article 94. Kreutzwiser, R., de Loë, R., Imgrund, K., Conboy, M.J., Simpson, H., & Plummer, R. (2011). Understanding stewardship behaviour: Factors facilitating and constraining private water well stewardship. Journal of Environmental Management, 92(4), 1104–1114. Machida, M., Murakami, M., & Goto, A. (2022). Di¡erences in data trustworthiness and risk perception between bar graphs and pictograms. International Journal of Environmental Research and Public Health, 19(8), Article 4690. ijerph19084690 Morris, L., Wilson, S., & Kelly, W. (2016). Methods of conducting e¡ective outreach to private well owners—A literature review and model approach. Journal of Water & Health, 14(2), 167–182. Ramirez-Andreotta, M.D., Brody, J.G., Lothrop, N., Loh, M., Beamer, P.I., & Brown, P. (2016). Improving environmental health literacy and justice through environmental exposure results communication. International Journal of Environmental Research and Public Health, 13(7), Article 690. Sanders, A.P., Messier, K.P., Shehee, M., Rudo, K., Serre, M.L., & Fry, R.C. (2012). Arsenic in North Carolina: Public health implications. Environment International, 38(1), 10–16. https://doi. org/10.1016/j.envint.2011.08.005 Segev, T., Harvey, A.P., Ajmani, A., Johnson, C., Longfellow, W., Vandiver, K.M., & Hemond, H. (2021). A case study in participatory science with mutual capacity building between university and tribal researchers to investigate drinking water quality in rural Maine. Environmental Research, 192, Article 110460. https://doi. org/10.1016/j.envres.2020.110460 Severtson, D.J., Baumann, L.C., & Brown, R. (2006). Applying a health behavior theory to explore the influence of information and experience on arsenic risk representations, policy beliefs, and protective behavior. Risk Analysis, 26(2), 353–368. https://doi. org/10.1111/j.1539-6924.2006.00737.x Tomlinson, M.S., Bommarito, P., George, A., Yelton, S., Cable, P., Coyte, R., Karr, J., Vengosh, A., Gray, K.M., & Fry, R.C. (2019). Assessment of inorganic contamination of private wells and demonstration of e¡ective filter-based reduction: A pilot-study in Stokes County, North Carolina. Environmental Research, 177, Article 108618. Tomsho, K.S., Schollaert, C., Aguilar, T., Bongiovanni, R., Alvarez, M., Scammell, M.K., & Adamkiewicz, G. (2019). A mixed methods evaluation of sharing air pollution results with study participants via report-back communication. International Journal of Environmental Research and Public Health, 16(21), Article 4183. Vengosh, A., Coyte, R., Karr, J., Harkness, J.S., Kondash, A.J., Ruhl, L.S., Merola, R.B., & Dywer, G.S. (2016). Origin of hexavalent chromium in drinking water wells from the Piedmont aquifers of North Carolina. Environmental Science & Technology Letters, 3(12), 409–414. Zheng, Y., & Flanagan, S.V. (2017). The case for universal screening of private well water quality in the U.S. and testing requirements to achieve it: Evidence from arsenic. Environmental Health Perspectives, 125(8), Article 085002. References continued from page 13 Three reasons to advertise right here in the Journal of the Environmental Health:͜ 20,000+ readers interested in environmental health͜ Delivered directly to email inboxes from a trusted source͜ Clickable and trackable links from your ad to your website We also have special rates for first-time advertisers and long-term contracts. Contact or 303-802-2133. You Are Seeing This Ad— Your Customers Will, Too!

April 2023 • 3962&0 3+ 2:.6321*28&0 *&08- 15 Do you know someone who is walking the walk? When your colleague or team steps up to create a more just, diverse, equitable, and inclusive environment, it matters! Let them know by nominating them today for the Dr. Bailus Walker, Jr. Diversity and Inclusion Awareness Award. Nomination Deadline: May 15, 2023 Dr. Bailus Walker, Jr. Diversity and Inclusion Awareness Award Recognize your colleague! Do you work with someone who is always coming up with creative ways to educate the public or colleagues? Is there someone on your team who has created tools or a practice that has really made a difference in improving environmental health? Nominate them for the Joe Beck Educational Contribution Award and show them how much you value their contribution. Nomination Deadline: May 15, 2023 Joe Beck Educational Contribution Award

16 $3091* • 91'*6 ADVANCEMENT OF THE SCIENCE Introduction 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 cardiovascular disease and metabolic syndrome (Chen et al., 2013). Outdoor physical activity, however, also exposes people to air pollutants 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 deposition of air pollutants in the lungs can occur due to increased respiratory intake (Giles & 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 inactivity (Roberts et al., 2014; Wen et al., 2009). For these reasons, exposure to an environment with an increased level of air pollution might lead to adverse health e•ects due to airway exposure to airborne pollutants from increased respiratory intake and also lack of physical activity. Air Pollutants in the School Environment Spending time in an environment near heavy tra–c is particularly harmful to children. 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 tra–c intersections or freeways where children might be exposed to higher levels of air pollution from tra–c. Coarse particulate matter (PM10 or particles <10 µm in aerodynamic diameter), fine particulate matter (PM2.5 or particles <2.5 µm in aerodynamic diameter), nitrogen dioxide (NO2), and ozone (O3) are some of the tra–c-related air pollutants to which children of roadside communities are commonly exposed. 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 a•ects children at a young age when they are likely to establish their health habits, it is important to emphasize physical activity with pediatric asthma patients (Mancuso et al., 2006). National management guidelines for asthma state that most people’s symptoms '786&(8 People with asthma, particularly young children, are more adversely a ected by tra c 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—PM2.5, PM10, nitrogen dioxide (NO2), and ozone (O3)—at the school for 10 weeks and measured physical activity levels via accelerometry in children (n = 12, ages 6–12 years). Concentrations of PM2.5, PM10, and NO2 were negatively associated with moderate to vigorous physical activity (PM2.5 and PM10: p < .001; NO2: p = .04) and positively associated with sedentary activity (PM2.5 and PM10: p < .001; NO2: 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. 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 Statistics, 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 Center for Community Health Impact, University of Texas Health Science Center School of Public Health Decreased Moderate to Vigorous Physical Activity Levels in Children With Asthma Are Associated With Increased Traffic-Related Air Pollutants