Exposure to environmental pollutants contributes to an increased risk for chronic diseases such as cardiovascular disease, diabetes, and cancer [1Ruzzin J, Petersen R, Meugnier E, et al. Persistent organic pollutant exposure leads to insulin resistance syndrome. Environ Health Perspect 2010; 118(4): 465-71.
[http://dx.doi.org/10.1289/ehp.0901321] [PMID: 20064776] -4Ludewig G, Robertson LW. Polychlorinated biphenyls (PCBs) as initiating agents in hepatocellular carcinoma. Cancer Lett 2013; 334(1): 46-55.
[http://dx.doi.org/10.1016/j.canlet.2012.11.041] [PMID: 23211541] ]. Most Americans, however, are not sufficiently familiar with environmental health risks and need guidance to respond with appropriate protective behaviors. Research has shown that healthy nutrition habits are essential components of strategies for helping people achieve optimum health and to modulate the severity of symptoms and disease progression for those suffering from chronic diseases [5Artinian NT, Fletcher GF, Mozaffarian D, et al. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: a scientific statement from the American Heart Association. Circulation 2010; 122(4): 406-41.
[http://dx.doi.org/10.1161/CIR.0b013e3181e8edf1] [PMID: 20625115] -7Gaetke LM, Stuart MA, Truszczynska H. A single nutrition counseling session with a registered dietitian improves short-term clinical outcomes for rural Kentucky patients with chronic diseases. J Am Diet Assoc 2006; 106(1): 109-12.
[http://dx.doi.org/10.1016/j.jada.2005.09.051] [PMID: 16390674] ]. As part of the National Institutes of Environmental Health Sciences (NIEHS) University of Kentucky’s Superfund Research Center (UK-SRC), researchers are now finding that good nutrition may also be a defense for combating the health effects of certain environmental pollutants [2Hennig B, Toborek M, Reiterer G, et al. Nutrition modulates PCB toxicity: Implications in atherosclerosis. In: Hansen LG, Robertson LW, Eds. PCBs: Human and Environmental Disposition and Toxicology. 2008; pp. 165-71.].

Persistent organic pollutants, such as polychlorinated biphenyls (PCBs), are used as the model Superfund toxicant [8Agency for Toxic Substances and Disease Registry [homepage on the Internet]. Atlanta, GA: Toxic Substance Portal, Polychlorinated Biphenyls (PCBs). [updated 2011 March 3; cited 2014 December 2]. Available from: http://www.atsdr.cdc.gov/ substances/toxsubstance.asp?toxid=26 ] in this research. For over twenty years, these researchers have studied PCBs and other chlorinated organic compounds, diet, oxidative stress, and the increased likelihood of developing chronic diseases, such as atherosclerosis, obesity, insulin resistance/diabetes, and cancer [2Hennig B, Toborek M, Reiterer G, et al. Nutrition modulates PCB toxicity: Implications in atherosclerosis. In: Hansen LG, Robertson LW, Eds. PCBs: Human and Environmental Disposition and Toxicology. 2008; pp. 165-71.-4Ludewig G, Robertson LW. Polychlorinated biphenyls (PCBs) as initiating agents in hepatocellular carcinoma. Cancer Lett 2013; 334(1): 46-55.
[http://dx.doi.org/10.1016/j.canlet.2012.11.041] [PMID: 23211541] ]. Oxidative stress plays an important role in the development of age-related diseases [9-11], and PCBs appear to contribute to oxidative damage in the body [1 - 4, 11, 12]. Scientific evidence increasingly suggests that poor diet may increase the risk for oxidative stress and chronic diseases [1 - 4, 9 - 12]. Nutrition is known to play a significant role in the prevention and management of these same chronic diseases and has been shown to modulate the toxicity of PCBs [1Ruzzin J, Petersen R, Meugnier E, et al. Persistent organic pollutant exposure leads to insulin resistance syndrome. Environ Health Perspect 2010; 118(4): 465-71.
[http://dx.doi.org/10.1289/ehp.0901321] [PMID: 20064776] -4Ludewig G, Robertson LW. Polychlorinated biphenyls (PCBs) as initiating agents in hepatocellular carcinoma. Cancer Lett 2013; 334(1): 46-55.
[http://dx.doi.org/10.1016/j.canlet.2012.11.041] [PMID: 23211541] , 11Majkova Z, Oesterling E, Toborek M, Hennig B. Impact of nutrition on PCB toxicity. Environ Toxicol Pharmacol 2008; 25(2): 192-6.
[http://dx.doi.org/10.1016/j.etap.2007.10.015] [PMID: 21783859] , 12Hennig B, Hammock BD, Slim R, Toborek M, Saraswathi V, Robertson LW. PCB-induced oxidative stress in endothelial cells: modulation by nutrients. Int J Hyg Environ Health 2002; 205(1-2): 95-102.
[http://dx.doi.org/10.1078/1438-4639-00134] [PMID: 12018021] ].

Translating this science-based nutrition research to protective public health nutrition recommendations and behaviors for those exposed to environmental insults is a fairly new concept, but shows promise for those affected [11Majkova Z, Oesterling E, Toborek M, Hennig B. Impact of nutrition on PCB toxicity. Environ Toxicol Pharmacol 2008; 25(2): 192-6.
[http://dx.doi.org/10.1016/j.etap.2007.10.015] [PMID: 21783859] -13Gaetke L, Gaetke K, Bowen C. Challenges to superfund community nutrition programs in Kentucky. Environ Toxicol Pharmacol 2008; 25(2): 277-81.
[http://dx.doi.org/10.1016/j.etap.2007.10.023] [PMID: 18443657] ]. This nutrition message is the basis for devising community nutrition and environmental health education programs, especially for communities with proximity to federally designated hazardous waste sites. Nutrition and other health care professionals play an important role in effectively disseminating this information.

One factor impacting the success of these community programs, however, has been the apparent lack of public awareness of environmental hazards, the health risks they entail, and the range of available responses to those risks. Studies have shown that nutrition education programs are more effective when tailored to the needs and beliefs of individuals in the target population [14Brug J, Glanz K, Van Assema P, Kok G, van Breukelen GJ. The impact of computer-tailored feedback and iterative feedback on fat, fruit, and vegetable intake. Health Educ Behav 1998; 25(4): 517-31.
[http://dx.doi.org/10.1177/109019819802500409] [PMID: 9690108] ], and this study attempts to learn more about the knowledge and perceptions of environmental health issues by certain populations in Kentucky.

The purpose of this study was to use an environmental health survey instrument to evaluate knowledge and awareness of pollution, environmental health risks, and protective health behaviors for more effective community nutrition and health education program planning. We considered several survey instruments. Most were developed for more narrowly defined populations or more specific types of environmental problems or health issues. The Perceived Environmental Risk (PER) survey, for example, was previously used to evaluate middle and high school students and teachers participating in environmental educational subjects [15Weber JM, Hair JJ, Fowler CR. Developing a measure of perceived environmental risk. J Environ Educ 2000; 32: 28-35.
[http://dx.doi.org/10.1080/00958960009598669] ]. Other studies have used surveys developed for those suffering from asthma [16Fitzclarence CA, Henry RL. Validation of an asthma knowledge questionnaire. J Paediatr Child Health 1990; 26(4): 200-4.
[http://dx.doi.org/10.1111/j.1440-1754.1990.tb02429.x] [PMID: 2257180] , 17Delclos GL, Arif AA, Aday L, et al. Validation of an asthma questionnaire for use in healthcare workers. Occup Environ Med 2006; 63(3): 173-9.
[http://dx.doi.org/10.1136/oem.2005.021634] [PMID: 16497858] ], for farm workers exposed to pesticides [18Arcury TA, Quandt SA, Russell GB. Pesticide safety among farmworkers: perceived risk and perceived control as factors reflecting environmental justice. Environ Health Perspect 2002; 110(Suppl. 2): 233-40.
[http://dx.doi.org/10.1289/ehp.02110s2233] [PMID: 11929733] ], and for those in a mining region in Mexico [19Catalán-Vázquez M, Schilmann A, Riojas-Rodríguez H. Perceived health risks of manganese in the Molango Mining District, Mexico. Risk Anal 2010; 30(4): 619-34.
[http://dx.doi.org/10.1111/j.1539-6924.2010.01377.x] [PMID: 20345581] ]. Because the focus of this study is the environmental awareness of broader community groups, these targeted approaches were not applicable to our purpose.

Ultimately, collaboration was formed between researchers at the University of Kentucky and researchers at Yale University to create a modified version of the validated Environmental Health Engagement Profile (EHEP) survey instrument, developed by Dixon, Hendrickson, Ercolano, Quackenbush, and Dixon (2009). The EHEP was originally developed for evaluating and working with communities on environmental health issues. In the survey, statements are rated to indicate awareness of environmental pollution in the immediate surroundings, perceptions and beliefs that pollution may cause negative health effects, acceptance of pollution as unavoidable, motivation to take personal actions to protect against pollution, and motivation to work with others to reduce pollution in the community [20Dixon JK, Hendrickson KC, Ercolano E, Quackenbush R, Dixon JP. The environmental health engagement profile: what people think and do about environmental health. Public Health Nurs 2009; 26(5): 460-73.
[http://dx.doi.org/10.1111/j.1525-1446.2009.00804.x] [PMID: 19706129] ].

In the present study, we tested the hypothesis that knowledge and perceptions of environmental health risks are associated with increased motivation to adopt appropriate protective nutrition and other lifestyle behaviors that improve health and mitigate the effects of environmental insults. We used a modified EHEP survey instrument and assessed its reliability with added nutrition questions.

The original validated EHEP survey instrument, published in detail elsewhere [20Dixon JK, Hendrickson KC, Ercolano E, Quackenbush R, Dixon JP. The environmental health engagement profile: what people think and do about environmental health. Public Health Nurs 2009; 26(5): 460-73.
[http://dx.doi.org/10.1111/j.1525-1446.2009.00804.x] [PMID: 19706129] ], was developed “for assessing the way people engage with environmental health issues.” It contains five scales or subject areas defined by statements related to environmental pollution. Participants rate the statements describing their awareness of types of pollution, concerns about pollution and health, and actions taken, individually or as a community, in response to pollution by using a number scale ranging from 0 to 10 with 10 always indicating greatest magnitude (Table 1): Scale 1, Pollution Sensitivity Scale, includes statements that ask about types of pollution in the participant’s neighborhood, 0 indicates [none at all] and 10 indicates [very serious problem]; Scale 2, Pollution Causes Illness Scale, and Scale 3, Pollution Acceptance Scale, include statements regarding concerns about pollution and health, 0 indicates [disagree completely] and 10 indicates [agree completely]; Scale 4, Personal Environmental Action Scale, and Scale 5, Community Environment Action Scale, include statements about personal and community actions taken by the participant, 0 indicates [never do this] and 10 indicates [always do this when it makes sense].

Table 1
Summary of environmental health engagement profile (EHEP) kentucky nutrition version survey scales and characteristics.

We modified the original EHEP by adding fourteen statements to incorporate nutrition concepts as they relate to environmental pollution and health. Each statement was written to have content appropriate for one of the five scales, and each scale included items with nutritional issues. Examples of the added nutrition statements are provided for each of the five scales: Pollution Sensitivity Scale – “contaminants like mercury, dioxin or PCBs [may exist] in fish, meat or poultry;” Pollution Causes Illness Scale – “people may get sick because they don’t eat the right foods to protect themselves from pollution;” Pollution Acceptance Scale – “many people I know don’t seem to get sick, even though they don’t try to keep contaminants out of their food;” Personal Environmental Action Scale – “I eat organically grown food as much as I can;” and Community Environmental Action Scale – “I talk with friends and neighbors about how we can get healthier foods in our town.”

The original EHEP survey instrument was reformatted from a telephone interview tool to one completed with paper and pencil and renamed the EHEP Kentucky Nutrition Version.

Using this new survey instrument, responses were collected from a general adult population (18 yrs and older) by UK-SRC’s researchers, which consisted of graduate students and faculty credentialed as registered dietitians. This was a convenience sample with no randomization of participants. We located and recruited participants from several of the University of Kentucky’s (UK’s) Cooperative Extension Service (CES) events and selected Kentucky community festivals between May and August, 2010. Five groups were formed based on proximity to hazardous waste sites. Kentucky has over 500 designated hazardous waste sites, which vary by state and federal designation in visibility and functioning status. Three of the four data collection events had proximity to designated U.S. Environmental Protection Agency (EPA) National Priorities List (NPL) sites. Hazardous waste sites are placed on the NPL to indicate that they are a priority due to release or possible release of hazardous contaminants and require further investigation and cleanup by the federal Superfund Program [21U.S. Environmental Protection Agency [homepage on the Internet] National Priorities List 2014. Available from: http://www.epa.gov/superfund/sites/npl. ]. Out-of-state participants were included depending on proximity to some of the events at the state’s borders, Ohio and Tennessee.

Data were collected based on the following five groups:

1. Statewide Extension Agents Group – participants were from UK’s CES Family and Consumer Sciences’ (FCSs’) agents attending an annual meeting representing 52 out of the 120 counties in the state (n=83);
2. County Homemakers Non-NPL Group – participants were members of a nonmetropolitan county’s annual meeting of the Kentucky Extension Homemakers Association homemakers. There were no nearby NPL sites (n=96);
3. Rural NPL Group - participants were attending an annual spring festival in a rural county in close proximity to a designated NPL site (n=172);
4. Metropolitan NPL Group - participants were attending the annual Kentucky State Fair in a large metropolitan area with three NPL sites (n=429); and
5. All Groups Combined and evaluated as one (n=774).

Completion of the survey was voluntary. Participants were given information about the survey with a cover letter as a waiver of consent. On completion, participants and other nonparticipating family members were offered optional free fresh fruit or granola bars and educational nutrition handouts. Review and approvals were obtained from the appropriate ethics committees. This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by the University of Kentucky’s Institutional Review Board.

Various demographic and lifestyle characteristics of possible impact on environmental health issues such as age, gender, education, and household members were assessed. No personal identifiers were included. Reliability analyses of each of the enhanced subscales of the EHEP were performed.

The new EHEP Kentucky Nutrition Version survey instrument used in this study assessed awareness, beliefs, perceptions, and behaviors of Kentucky citizens pertaining to pollution and environmental health risks. Each of the five scales of the new survey instrument had Cronbach’s alpha indicating acceptable internal consistency reliability. The results provide helpful findings for developing successful nutrition and health programs for individuals and communities affected by environmental pollutants.

First, the survey results confirmed that we need to know some details about the audience’s level of awareness of environmental issues and the health risks they entail in designing effective nutrition and health programs for them. In reporting awareness of various pollution issues in their neighborhoods, the mean score for all five groups was low (3.44), supporting a need for education on types of pollution and the seriousness of the pollution before establishing a link to pollution causes illness and encouraging personal environmental actions. The Statewide Extension Agents Group had the highest mean score (3.76), and the County Homemakers Non-NPL Group had the second highest mean score (3.74) (Table 3). Both of these groups were closely connected with UK’s CES, which suggests that their members may have been more likely to have participated in CES educational programs, which include such topics as agriculture, food, home, family, and the environment.

On the other hand, the Rural NPL Group was more concerned with health risks, as indicated by having the highest mean score (4.71) for Pollution Causes Illness Scale, while the Metropolitan NPL Group had the second highest mean (4.55) for that Scale. Thus, the groups having the highest level of awareness of the health risks posed by pollution are those with nearby NPL sites. This finding was not surprising, as the EPA procedure for NPL site remediation is designed to include community members through public notification, a public comment period, and ongoing consideration of community member attitudes. Further, participants in the group from the Rural NPL Group were from a smaller town and thus more likely to be aware of the history and publicity pertaining to the nearby NPL site. Some may have had family or friends who developed health problems from working at or living near the site. Conversely, the employer may have provided a lucrative source of employment in the region with subsequent loss of this revenue having a negative impact on the community. The Metropolitan NPL Group came from a much larger populated area containing three NPL sites, and participants may have been exposed to media coverage on three sites even if they were not familiar with the actual victims of the pollution.

Interestingly, however, the Statewide Extension Agents Group, which had the highest mean score for the Pollution Sensitivity Scale, as noted above, had the lowest mean score on Pollution Causes Illness Scale (Table 3). Thus, although this group’s members were aware of pollution in their neighborhoods, they were less likely to perceive the health threats involved. These participants may not have had personal experiences with living near a NPL or other polluted sites and, therefore, did not feel victimized even though they knew intellectually that pollution may cause health problems. In addition, the “neighborhood halo effect,” may have contributed to this group’s responses [19Catalán-Vázquez M, Schilmann A, Riojas-Rodríguez H. Perceived health risks of manganese in the Molango Mining District, Mexico. Risk Anal 2010; 30(4): 619-34.
[http://dx.doi.org/10.1111/j.1539-6924.2010.01377.x] [PMID: 20345581] ]. Social and geographic distancing from a hazardous waste site may imply that the environmental harms are someone else’s problem, and there is less reason or ability to confront the issues in spite of environmental exposures. An effective community nutrition and health program, therefore, would need to assess the precise area of needed attention.

The second finding of importance was that all the groups in the survey showed willingness to take individual action to protect against environmental health issues, as indicated by higher mean scores (above 5.0 on 0-10 scale) for the Personal Environmental Action Scale, compared to the mean scores for the other Scales (Table 3). The Rural NPL Group had the highest mean score (4.71) for the Personal Environmental Action Scale. When comparing scales (Table 4), there was a statistically significant positive correlation in all groups, separately and combined, between Pollution Causes Illness Scale and Personal Environmental Action Scale. This suggests that participants were receptive to learning how to make individual protective behavior changes to address health issues. It also reinforces health behavior models that indicate that individuals must be aware of and perceive health risks to motivate them to take corrective action [22Bhargava A, Hays J. Behavioral variables and education are predictors of dietary change in the Women’s Health Trial: Feasibility Study in Minority Populations. Prev Med 2004; 38(4): 442-51.
[http://dx.doi.org/10.1016/j.ypmed.2003.11.014] [PMID: 15020177] -25Merriam PA, Tellez TL, Rosal MC, et al. Methodology of a diabetes prevention translational research project utilizing a community-academic partnership for implementation in an underserved Latino community. BMC Med Res Methodol 2009; 9: 20-9.
[http://dx.doi.org/10.1186/1471-2288-9-20] [PMID: 19284663] ].

There was also a positive correlation between Pollution Causes Illness Scale and Community Environmental Action Scale (P < .05) for all groups except the County Homemakers Non-NPL Group (Table 3). Thus, in most cases, the participants were willing to work with others in the local community on health issues. The difference in response to taking community action may also be explained by the County Homemakers Non-NPL Group not having a nearby NPL site.

Third, there was a relationship between participants’ demographic characteristics and knowledge and perceptions of environmental health risks. The data showed that females were more concerned about health risks and were more likely to make protective individual behavior changes in response to environmental insults. Other researchers support this finding and report that, compared to females, males perceive fewer health risks from environmental causes and are more accepting of health risks that can occur [26Brent K. Gender, race, and perceived environmental risk: The “white male” effect in Cancer Alley, LA. Sociol Spectrum. Mid-South Sociol Assoc 2004; 24: 453-78., 27Flynn J, Slovic P, Mertz CK. Gender, race, and perception of environmental health risks. Risk Anal 1994; 14(6): 1101-8.
[http://dx.doi.org/10.1111/j.1539-6924.1994.tb00082.x] [PMID: 7846319] ]. Furthermore, a younger adult was more likely to be aware of pollution, but an older person was more likely to take individual action and community action to reduce environmental insult. Younger adults may be more aware of environmental issues from science classes in school, but recent trends show young people feel less personally responsible for environment concerns than they did in the early 1990s [28Wray-Lake L, Flanagan CA, Osgood DW. Examining trends in adolescent environmental attitudes, beliefs, and behaviors across three decades. Environ Behav 2010; 42(1): 61-85.
[http://dx.doi.org/10.1177/0013916509335163] [PMID: 20046859] ]. In contrast, either as workers or through local politics and publicity [19Catalán-Vázquez M, Schilmann A, Riojas-Rodríguez H. Perceived health risks of manganese in the Molango Mining District, Mexico. Risk Anal 2010; 30(4): 619-34.
[http://dx.doi.org/10.1111/j.1539-6924.2010.01377.x] [PMID: 20345581] ], older age groups are more aware of the local history of hazardous waste sites and the specific environmental health issues they present.

Participants with children were more likely to take individual action and to collaborate with others in the community to reduce health threats from pollution than participants without children. The multiple linear regression analyses (Table 5) supported these findings, which suggest that nutrition and environmental health programs will be more effective if they address such audience characteristics as age, gender, and members in the household to focus on the needed areas of attention.

Although the use of nutrition recommendations to improve health in response to exposures to environmental pollutants is relatively new, some of the rankings of individual statements within the scales show promise (Table 6). The Personal Environmental Action Scale, for example, had the highest overall means, indicating that participants reacted more favorably to taking individual protective actions in response to environmental threats than any of the other scales. Healthy nutrition and food recommendations were included in the Personal Environmental Action Scale. While merely stating or suggesting nutritional habits is seldom sufficient to inspire a change in dietary behavior [22Bhargava A, Hays J. Behavioral variables and education are predictors of dietary change in the Women’s Health Trial: Feasibility Study in Minority Populations. Prev Med 2004; 38(4): 442-51.
[http://dx.doi.org/10.1016/j.ypmed.2003.11.014] [PMID: 15020177] -25Merriam PA, Tellez TL, Rosal MC, et al. Methodology of a diabetes prevention translational research project utilizing a community-academic partnership for implementation in an underserved Latino community. BMC Med Res Methodol 2009; 9: 20-9.
[http://dx.doi.org/10.1186/1471-2288-9-20] [PMID: 19284663] ], nutrition programs should capitalize on this interest and motivation.

It is noteworthy that certain nutrition-related statements were ranked higher in importance by the participants in each of the scales (Table 6). In the Pollution Sensitivity Scale, for example, All Groups Combined ranked [pesticides, hormones, antibiotics in our food], as the fourth most commonly recognized problem in their neighborhood. The same group ranked [people may get sick because they don’t eat the right foods to protect themselves from pollution], fourth highest in the Pollution Causes Illness Scale. In the Personal Environmental Action Scale, the same group ranked [I wash my fruits and vegetables thoroughly before using them] as most frequent among behaviors listed. The same group ranked, [I talk with my friends and neighbors about how we can get healthier foods in our town] as the second most likely action they would take for their community. These responses reflect the importance of educating and motivating nutrition practices as a way to improve individual health habits and offer promise for those programs’ success.

This study has several limitations. The sample was limited to pre-arranged events or meetings which varied in their focus in comparison to pollution issues. The data collection relied on self-reporting which may be more or less consistent with actual behavior [22Bhargava A, Hays J. Behavioral variables and education are predictors of dietary change in the Women’s Health Trial: Feasibility Study in Minority Populations. Prev Med 2004; 38(4): 442-51.
[http://dx.doi.org/10.1016/j.ypmed.2003.11.014] [PMID: 15020177] -25Merriam PA, Tellez TL, Rosal MC, et al. Methodology of a diabetes prevention translational research project utilizing a community-academic partnership for implementation in an underserved Latino community. BMC Med Res Methodol 2009; 9: 20-9.
[http://dx.doi.org/10.1186/1471-2288-9-20] [PMID: 19284663] ]. The EHEP Kentucky Nutrition version, however, does have strong reliability. Similarity of these results to those previously reported (with the original EHEP) suggests validity, indicating that this survey provided an important tool for assessing concerns about environmental pollution and actions taken to protect health from such problems [20Dixon JK, Hendrickson KC, Ercolano E, Quackenbush R, Dixon JP. The environmental health engagement profile: what people think and do about environmental health. Public Health Nurs 2009; 26(5): 460-73.
[http://dx.doi.org/10.1111/j.1525-1446.2009.00804.x] [PMID: 19706129] ].

Results of this survey indicate that those developing community nutrition and environmental health programs to ameliorate the harm from environmental insults could augment their potential success by assessing and addressing a number of details regarding the audience’s knowledge of environmental pollutants and related health risks. The EHEP Kentucky Nutrition Version offers a useful device for that assessment. Armed with this information, those planning such programs may influence the audience’s motivation to undertake protective measures.