Improving Environmental Health Literacy and Justice through Environmental Exposure Results Communication

Understanding the short- and long-term impacts of a biomonitoring and exposure project and reporting personal results back to study participants is critical for guiding future efforts, especially in the context of environmental justice. The purpose of this study was to evaluate learning outcomes from environmental communication efforts and whether environmental health literacy goals were met in an environmental justice community. We conducted 14 interviews with parents who had participated in the University of Arizona’s Metals Exposure Study in Homes and analyzed their responses using NVivo, a qualitative data management and analysis program. Key findings were that participants used the data to cope with their challenging circumstances, the majority of participants described changing their families’ household behaviors, and participants reported specific interventions to reduce family exposures. The strength of this study is that it provides insight into what people learn and gain from such results communication efforts, what participants want to know, and what type of additional information participants need to advance their environmental health literacy. This information can help improve future report back efforts and advance environmental health and justice.


Single)exposure)measurements)are)"snapshots)in)time".)))
We are measuring metal concentrations at a single point in time. Measuring metal concentrations with a single sampling does not establish what the exposures were in the past or what they may be in the future. Some exposure measurements can only reflect exposure over The National Health and Nutrition Examination Survey (NHANES), is a U.S. Centers for Disease Control and Prevention program that examines about 5,000 people per year to assess environmental exposures, health, and nutrition status across the United States. Where NHANES data is available for metal concentrations in urine, we have provided reference values for the 50 th and 95 th percentile of the children surveyed. The 50 th percentile value means that half the children between ages 6 and 11 surveyed had urine metal measurements below this value and half were above that value. The 95 th percentile value means that only 5% of the children had urine metal concentrations higher than that value. These percentile values are not health standards or guidelines; they simply show the distribution of urine metal concentrations of children ages 6-11 surveyed in NHANES.

Talk)to)your)family)doctor)about)health)concerns)related)to)metals)exposure.)))
Speaking with your primary doctor or your local health care center is a good starting point in understanding health consequences of metals exposure. Your doctor may be able to address your concerns, or he or she may refer you to a board-certified physician who specializes in medical toxicology or occupational and environmental medicine. While study investigators at the University of Arizona are available to share general knowledge about metals exposures and possible health effects, your primary doctor is the best person to address specific health questions.

Urine)was)not)analyzed)at)a)certified)clinical)laboratory.)
MESH is a university project aimed at understanding exposure to metals; therefore, we chose to analyze urine samples at University of Arizona laboratory facilities. However, these facilities are not certified as clinical laboratories. The analysis procedures and results are checked for quality according to research criteria, not clinical criteria. Only certified clinical laboratories can provide analyses and results on which healthcare decisions can be based. For more information about certified clinical laboratories please visit the website in the Additional Information section.
•* ADEQ Soil Remediation Level -A level of metal in soil in a residential area that may trigger further study or investigation, but does not necessarily warrant cleanup. This level is determined by the Arizona Department of Environmental Quality. Concentration"(mg/kg) Nickel 10" " Metals'in'Your'Vacuum'Dust' ' ' ' Note:"There"are"no"guidelines"for" contaminants"in"house"dust,"so"we" have"included"soil"guidelines"for" comparison." Concentration"(mg/kg)

Results'References'
Please visit these websites listed by subject to find information used in this results packet. cdc.gov/exposurereport/pdf/FourthReport_UpdatedTables_Mar2013.pdf and browse to the "Metals and Metalloids" section. Find charts that read, "Urinary *Metal* (creatinine corrected)" in the top left corner. For example, "Urinary Total Arsenic (creatinine corrected)". In the first column, navigate to the "Age Group -6-11 years"; this relates to the ages of children sampled. Next, move to the second column and find the row "09-10" for "6-11 years"; this denotes the years kids 6-11 years were sampled: [2009][2010]. See values in this row that fall in the "50 th " and "95 th " percentiles columns.

Additional'Information'
Please visit these websites listed by subject to find additional information.  (MESH). This packet shows the test results of your children's urine, toenails, and blood and your home's drinking water, yard soil, and vacuum dust compared to those of other MESH participant households. All of these samples have been tested for seven metals: aluminum, arsenic, beryllium, cadmium, chromium, lead, and nickel, with the exception of your children's blood, which was tested for only lead. This packet is the second of two results packets. If you did not receive your first packet, please contact Nathan Lothrop toll-free at (877) 535-6171.

•! Agency for Toxic Substances and Disease Registry Toxicological
We are trying to understand how much you and your family are exposed to metals. We are also trying to understand how metals can enter the home. Results from this study are helping us determine how people can reduce their exposure to metal contaminants; however, we are still analyzing study results to find additional ways you can reduce your exposure to metals.
In this packet, we have included the following: •' a summary of the study results; •' ways you can reduce your exposure to metals; •' important information about MESH; •' a glossary of terms that describes information you will find in your results; and •' additional information on the environmental and health guidelines.
Please keep in mind that the methods used in this study were designed for research purposes only and do not necessarily follow US Environmental Protection Agency or Clinical Laboratory Improvement Amendments standard methods.
If you have questions, please contact Nathan Lothrop toll-free at (877)

Study&Summary& BACKGROUND&
Thank you again for participating in the Metals Exposure Study in Homes (MESH); we could not have done this without you! MESH began in 2012 in response to Dewey-Humboldt community concerns about whether contamination from the Iron King Mine and Humboldt Smelter Superfund Site (the Superfund Site) was entering people's bodies at harmful levels. We investigated if levels of metals found in the environment and in people's bodies in Dewey-Humboldt are higher than environmental and health guidelines. Altogether, 70 children 1-11 years of age from 34 homes in the Dewey-Humboldt area participated in MESH ( Figure 1).
We analyzed children's urine, toenails, and blood, as well as drinking water, yard soil, and vacuum dust from their homes. Samples were tested for seven metals: aluminum, arsenic, beryllium, cadmium, chromium, lead, and nickel, with the exception of blood, which was tested only for lead. We focused on these seven metals because the US Environmental Protection Agency (EPA) noted them as metals of potential concern based on air and soil samples taken on or near the Superfund Site in its 2010 Remediation Investigation of the Superfund Site. For more information about this report and other EPA work at to the Superfund Site, please visit the EPA website in the Additional Information section.
We focused on children for two reasons: 1) children are still growing and may be more susceptible to health effects of high exposures to pollutants; and 2) children are more likely than adults to put their hands or objects like toys into their mouths, which may be covered with soil and dust. It is important to know that the metals we tested occur naturally in the environment, including in Arizona, and can also come from man-made sources, such as lead in older paint. So, even if the Superfund Site were not present, residents could still be exposed to these metals from other sources.

RESULTS&
Overall, we found that levels of most metals were below the Maximum Contaminant Level (MCL) in drinking water and below the Arizona Department of Environmental Quality Soil Remediation Level (AZ SRL) in yard soil and vacuum dust in MESH homes. However, arsenic levels in drinking water, yard soil, and vacuum dust were above these respective guidelines for many MESH homes. In addition, we found most metals levels in urine for most children in MESH were below those of a typical child in the US. However, arsenic levels in urine for most children in MESH were higher than a typical child in the US.
Based on these results, we believe that MESH participants have higher levels of exposures to arsenic compared to typical US residents (Figure 2). Concentrations of all seven metals in drinking water, yard soil, vacuum dust, urine, and toenails and lead in blood, for your household and for other MESH households, are found in later sections. In the summary sections that begin on the next page, we only focus on arsenic in urine, drinking water, yard soil, and vacuum dust and lead in blood. Toenails are not included in the summarized results because there is no guideline for comparison.

REDUCING&YOUR&EXPOSURE&TO&ARSENIC&
During the study, we tried to speak with a parent or guardian about their household's results and how they compared to guidelines. If you were not called about your results and would like to discuss them, please call Nathan Lothrop toll-free at (877) 535-6171.
For suggestions on how to reduce your exposure to arsenic, please read the following summarized results sections and the included factsheets, "Arsenic in drinking water: what you need to know" and "How to Reduce Your Exposure to Arsenic and Lead in Dewey-Humboldt, Arizona." If you still have questions or concerns, please call Nathan Lothrop toll-free at (877)

Urine& INTRODUCTION&
Arsenic and other metals found in urine can come from many sources. MESH was designed to estimate your potential exposure from common sources of these metals, such as drinking water, yard soil, and house dust (measured in vacuum dust). We did this by taking samples from your home environment and your children, and with questionnaires and food and activity diaries. Arsenic is also found in certain foods; however, we were unable to sample any food. For information about arsenic in food (including drinks), please visit the Food and Drug Administration website found in the Additional Information section.

RESULTS&
Overall, most metals were below the median level of children in a national study (the National Health and Nutrition Examination Survey, NHANES) conducted regularly by the US Centers for Disease Control and Prevention (CDC) (Figure 3). This median level is also called the NHANES 50 th percentile, which means 50% (half) of children's values in NHANES are below this value, and 50% (half) are above it. However, the arsenic level in urine was above the NHANES 50 th percentile for 56 of 68 children (82%) in MESH, compared to a group of 68 typical children, in which only 34 of 68 children (50%) would have arsenic levels in urine above the NHANES 50 th percentile. ! However, arsenic levels in urine of MESH participants are generally similar to those of other Arizona residents of all ages.
Based on these results in urine, we believe that MESH participants have higher exposures to arsenic compared to typical US residents. At the same time, these results are similar to those that have been measured in other Arizona residents of all ages.

INTERPRETING&ARSENIC&LEVELS&IN&YOUR&CHILD'S&URINE
Currently, there is no health standard or guideline for arsenic in urine for children. Given this, if you are concerned about your child's urinary arsenic level, start reducing their potential exposure to arsenic from drinking water, yard soil, and house dust using tips from the following sections and in the included factsheets, "Arsenic in drinking water: what you need to know" and "How to Reduce Your Exposure to Arsenic and Lead in Dewey-Humboldt, Arizona." Additionally, it is important to remember that urine shows how much of a metal was absorbed by the body in the previous 3-4 days. As a result, a single urine test may not give an accurate picture of past (or future) exposures.
Finally, ask your family doctor for help understanding possible health risks from exposure to arsenic. If your family doctor is unsure how to interpret your child's urine results, please have him or her call Nathan Lothrop at (877) 535-6171 for referral to a board-certified physician who specializes in medical toxicology or occupational and environmental medicine.

Blood& RESULTS&
None of the 46 children (0%) in MESH who had their blood tested for lead had levels above the reference value of 5 µg/dL set by the CDC (Figure 4). Based on this, we do not believe lead exposure is a particular concern for residents in and around Dewey-Humboldt. The Arizona Department of Health Services recommends all children in Arizona have their blood tested for lead at age 1, and again at age 2. If you think your child of any age has come in contact with lead, test that child's blood for lead.& Figure&4:!None!of!the!46!children!(0%)!in! MESH!who!had!their!blood!tested!for!lead! had!lead!levels!above!the!reference!value! set!by!the!CDC.!! 8! ! Drinking&Water& RESULTS& While levels of most metals in drinking water were below the Maximum Contaminant Level (MCL) set by the EPA, arsenic levels in drinking water were above the MCL in 19 of 33 (56%) homes in MESH ( Figure  5). In this case, drinking water is not treated by an in-home reverse osmosis system, which can reduce arsenic levels in water. The MCL is the maximum amount of a contaminant allowed in drinking water so that it is still safe to drink over many years. The MCL for arsenic is 10 parts per billion (ppb); this may also be written as 10 micrograms per liter (µg/L).
We found the highest arsenic levels in private wells, with the highest value being 26 times that of the MCL. However, this does not mean that all private wells had arsenic levels above the MCL. In addition, some homes using Humboldt Water Company water had arsenic levels above the MCL, with the highest value being 3 times that of the MCL. Humboldt Water Company is aware of this issue and is currently installing a treatment system to reduce the arsenic in their water. !

ARSENIC&IN&DRINKING&WATER:&WHAT&YOU&NEED&TO&KNOW&
High arsenic levels are present in groundwater in the Dewey-Humboldt area. Please refer to the enclosed factsheet, "Arsenic in drinking water: what you need to know," for information and resources on reducing arsenic in drinking water. Further, the Arizona Department of Health Figure&5:!The!arsenic!level!in!drinking!water!was!above!the!MCL!in!19! of!33!homes!(56%)!in!MESH.

9! !
Services advises the following actions if the arsenic level in your water is above the MCL of 10 parts per billion (ppb): •' If the arsenic level in your water is between 10 -200 ppb, it is not an emergency, but make plans to get water for drinking and cooking from a different source, or install and maintain a reverse osmosis home treatment system. •' If the arsenic level in your water is over 200 ppb, DO NOT use this water for drinking or cooking. Use another water source immediately until you can install and maintain a home treatment system. If the arsenic level in your water is less than 500 ppb, you can continue to use this water for bathing and washing clothes and dishes.
If you use a private well, test your water at least once every three years to determine the amount of arsenic and other metals in your water.

& Yard&Soil&and&Vacuum&Dust&& INTRODUCTION&
We used the Arizona Department of Environmental Quality Soil Remediation Level (AZ SRL) as a reference for metal concentrations in yard soil and vacuum dust. We are comparing vacuum dust levels to the AZ SRL since there are no guidelines for vacuum dust. The AZ SRL is a yard soil screening level based on a health risk assessment not specific to conditions in Dewey-Humboldt. Metal levels in soil higher than the AZ SRL do not necessarily require cleanup. The EPA, the Agency for Toxic Substances and Disease Registry (ATSDR), and the Arizona Department of Health Services (ADHS) are currently investigating soils in this area to determine if there is a health risk to residents from the metals in local soils. Dewey-Humboldt residents should refer to the results of the EPA, ATSDR, and ADHS study for guidance on whether their yard soil poses health risks and if it will be cleaned up. Until these results are available, preventing outdoor soil from coming into your home is one way of reducing arsenic levels in your vacuum dust.&

RESULTS&
Levels of most metals in yard soil and vacuum dust (previously referred to as Personal Vacuum Bag Dust) were below the AZ SRL. Arsenic levels were above the AZ SRL in yard soil for 27 of 34 homes (79%) in MESH (Figure 6). Arsenic levels in vacuum dust were above the AZ SRL in 17 of 31 homes (55%) (Figure 7).

REDUCING&YOUR&EXPOSURE&TO& YARD&SOIL&AND&VACUUM&DUST&& WITH&HIGH&ARSENIC&LEVELS&
Frequent vacuuming with a HEPA filter, wet dusting and mopping, and not wearing shoes indoors are ways of reducing the amount of dust that come into your home from outside. For more information on reducing your exposure to outdoor dust in your home, please refer to the enclosed factsheet "How to Reduce Your Exposure to Arsenic and Lead in Dewey-Humboldt, Arizona."

Exposure&to&Arsenic&and&Health&Effects&
The findings of MESH (higher levels of arsenic in urine, drinking water, yard soil, and vacuum dust) do not mean that MESH participants will have health problems from exposure to arsenic. We cannot determine whether a person's current health problems are due to his or her exposure or whether a person will develop future health problems. Researchers are still studying the relationship between levels of arsenic in the body and various diseases.
If arsenic levels in your water are above the Maximum Contaminant Level (MCL), we recommend reducing your exposure with methods outlined in the enclosed factsheet, "Arsenic in drinking water: what you need to know." If arsenic levels in your yard soil or vacuum dust are above the Arizona Department of Environmental Quality Soil Remediation Level (AZ SRL), we recommend reducing your exposure with methods outlined in the enclosed factsheet, "How to Reduce Your Exposure to Arsenic and Lead in Dewey-Humboldt, Arizona." In addition, your family doctor may be able to help you understand possible health risks from exposure to levels of metals above guidelines.
If your family doctor is unsure how to interpret your child's urine results, please have him or her call Nathan Lothrop toll-free at (877) 535-6171 for referral to a board-certified physician who specializes in medical toxicology or occupational and environmental medicine.

If you have any questions or concerns regarding:
•' …results in this packet, please contact Nathan Lothrop toll-free at (877)  An epidemiology study attempts to explain the relationship between an exposure and a health outcome in a defined group of people. For example, large-scale epidemiology studies established that smoking cigarettes (an exposure) increases the risk of lung cancer (a health outcome). An exposure study is designed to determine and understand the contact a person has with an environmental factor. MESH is an exposure study designed to find out if people are coming into contact with metals through drinking water, yard soil, or house dust and how much exposure they may be getting. Though MESH did collect some health information in a questionnaire, this was done to see if health outcomes should be assessed in a future study. At the moment, we are still analyzing data to determine if any health outcomes should be evaluated in the future.

MESH&is&designed&to&help&us&understand&which&factors&can&contribute&to& increased&metals&exposures.&
This study is investigating housing characteristics, behavior routines, general demographic information, and several other factors to see how these may impact the levels of metals in your home. We will use this information to provide additional suggestions to participants and other community members about how they can reduce their exposure to metals. However, we have not yet completed these more complex analyses. Nevertheless, there are many effective ways to reduce your exposure to metals, as outlined in this packet and in the included factsheets.

Metals&occur&naturally&in&the&environment.&&
Some areas have naturally higher levels of metals than others (which explains why mines are usually developed in such areas with higher levels of metals). Furthermore, while we can measure the level of a metal in certain substances like water or soil, it is difficult to know the original source of the metal. For example, arsenic may be found in soil in many parts of Arizona simply because it naturally occurs there. Similarly, some drinking water wells may have high arsenic concentrations because rock touching the well water has arsenic in it. Arsenic can also be found in some foods and drinks and in pressure-treated wood manufactured before 2004. One objective of MESH is to determine if living closer to the Superfund Site is associated with higher levels of exposure to certain metals for residents in and around Dewey-Humboldt. However, we have not yet completed these more complex analyses. As a result, we do not yet know if, and to what extent, the Superfund Site contributes to metals exposure in people.

13! !
Single&exposure&measurements&are&"snapshots&in&time."&& We measured metal concentrations at a single point in time. Measuring metal concentrations with a single sampling does not establish what the exposures were in the past or what they may be in the future. Some exposure measurements can only reflect exposure over very short time periods. For example, arsenic testing in urine only reflects arsenic exposure over the past several days. Likewise, metal concentrations in house dust may change from week to week, depending on the dust sources and the frequency of cleaning. As a result, measurements taken only once may not give an accurate picture of past (or future) exposures. This is important, because many chronic diseases associated with environmental exposures only happen after long periods of exposure.

Where&available,&we&have&used&NHANES&measurements&as&points&of&reference& for&urine&metal&concentrations.&
The National Health and Nutrition Examination Survey (NHANES), is a US Centers for Disease Control and Prevention program that annually examines about 5,000 people as young as 6 years of age across the United States to assess environmental exposures, health, and nutrition status. Where NHANES data is available for metal concentrations in urine, we have provided reference values for the 50 th and 95 th percentile of the children surveyed. The 50 th percentile value means that half the children between ages 6 and 11 surveyed had urine metal measurements below this value and half were above that value. The 95 th percentile value means that only 5% of the children had urine metal concentrations higher than that value. These percentile values are not health standards or guidelines; they simply allow us to compare our results to the results of children ages 6-11 from across the nation, surveyed in NHANES. In MESH, we also enrolled children ages 1-5, but NHANES does not have urine metal concentrations for this age range.

Talk&to&your&family&doctor&about&health&concerns&related&to&metals&exposure.&&
Speaking with your primary doctor or your local health care center is a good starting point in understanding health risks of metals exposure. While study investigators at the University of Arizona are available to share general knowledge about metals exposures and possible health effects, your primary doctor is the best person to address specific health questions. If your family doctor is unsure how to interpret your child's urine results, please have him or her call Nathan Lothrop toll-free at (877) 535-6171 for referral to a board-certified physician who specializes in medical toxicology or occupational and environmental medicine.

14! !
Urine,&drinking&water,&yard&soil,&and&vacuum&dust&were&analyzed&at&University&of& Arizona&laboratory&facilities.& MESH is a university project aimed at understanding exposure to metals; therefore, we chose to analyze urine, drinking water, yard soil, and vacuum dust samples at University of Arizona laboratory facilities. Although these facilities are not certified as clinical laboratories, our procedures and results undergo rigorous quality control testing according to research criteria. Our methods differ from clinical or EPA methods because they are designed for research purposes, and cannot serve as the basis for healthcare decisions or environmental cleanup action. For more information about certified clinical laboratories, please visit the Clinical Laboratory Improvement Amendments website found in the Additional Information section.

Understanding&Your&Results&
Your results are divided by type of sample (e.g., water, soil, urine). Each result chart shows test results for detected metal contaminants.

Important&Terms&
Here is a set of terms you will see throughout your results: •' AZ SRL (Arizona Department of Environmental Quality Soil Remediation Level) -The AZ SRL is a yard soil screening level based on a health risk assessment not specific to conditions in Dewey-Humboldt. If a metal concentration in residential yard soil is above the AZ SRL, it suggests further study, but does not necessarily require cleanup. This level is set by the Arizona Department of Environmental Quality.
•' Concentration -The amount of metal in a given volume or mass of sample, such as: µg/L, mg/kg, µg/g, or µg/dL. Sample types include water, yard soil, vacuum dust, urine, toenails, and blood.
•' MCL (Maximum Contaminant Level) -The MCL is the maximum amount of a contaminant allowed in drinking water so that it is still safe to drink over many years. This level is set by the US Environmental Protection Agency.
•' µg/L (Micrograms per Liter) -A measure of how many micrograms (one-thousandth of a milligram) of a substance (such as a metal) are in a liter of liquid (such as water or urine). This measure is also referred to as parts per billion (ppb). For perspective, 1 µg/L or ppb is the equivalent to a drop of ink in a backyard swimming pool.
•' mg/kg (Milligrams per Kilogram) -A measure of how many milligrams of a substance (such as a metal) are in a kilogram of a solid (such as yard soil or vacuum dust). This measure is also referred to as parts per million (ppm). For perspective, 1 mg/kg or ppm is the equivalent to one penny in $10,000 in pennies.
•' µg/g (Micrograms per Gram) -A measure of how many micrograms of a substance (such as a metal) are in a gram of a solid (such as toenails). This measure is also referred to as parts per million (ppm).
•' µg/dL (Micrograms per Deciliter) -A measure of how many micrograms of a substance (such as lead) are in a liter of liquid (such as blood).