Behavioral determinants of arsenic-safe water use among Great Plains Indian Nation private well users: results from the Community-Led Strong Heart Water Study Arsenic Mitigation Program.

BACKGROUND: The objective of this study was to evaluate the behavioral determinants associated with exclusive use of arsenic-safe water in the community-led Strong Heart Water Study (SHWS) arsenic mitigation program. METHODS: The SHWS is a randomized controlled trial of a community-led arsenic mitigation program designed to reduce arsenic exposure among private well users in American Indian Great Plains communities. All households received point-of-use (POU) arsenic filters installed at baseline and were followed for 2 years. Behavioral determinants selected were those targeted during the development of the SHWS program, and were assessed at baseline and follow-up. RESULTS: Among participants, exclusive use of arsenic-safe water for drinking and cooking at follow-up was associated with higher self-efficacy for accessing local resources to learn about arsenic (OR: 5.19, 95% CI: 1.48-18.21) and higher self-efficacy to resolve challenges related to arsenic in water using local resources (OR: 3.11, 95% CI: 1.11-8.71). Higher commitment to use the POU arsenic filter faucet at baseline was also a significant predictor of exclusive arsenic-safe water use for drinking (OR: 32.57, 95% CI: 1.42-746.70) and cooking (OR: 15.90, 95% CI: 1.33-189.52) at follow-up. From baseline to follow-up, the SHWS program significantly increased perceived vulnerability to arsenic exposure, self-efficacy, descriptive norms, and injunctive norms. Changing one's arsenic filter cartridge after installation was associated with higher self-efficacy to obtain arsenic-safe water for drinking (OR: 6.22, 95% CI: 1.33-29.07) and cooking (OR: 10.65, 95% CI: 2.48-45.68) and higher perceived vulnerability of personal health effects (OR: 7.79, 95% CI: 1.17-51.98) from drinking arsenic-unsafe water. CONCLUSIONS: The community-led SHWS program conducted a theory-driven approach for intervention development and evaluation that allowed for behavioral determinants to be identified that were associated with the use of arsenic safe water and changing one's arsenic filter cartridge. These results demonstrate that theory-driven, context-specific formative research can influence behavior change interventions to reduce water arsenic exposure. The SHWS can serve as a model for the design of theory-driven intervention approaches that engage communities to reduce arsenic exposure. TRIAL REGISTRATION: The SHWS is registered with ClinicalTrials.gov (Identifier: NCT03725592).

Evaluation of a water arsenic filter in a participatory intervention to reduce arsenic exposure in American Indian communities: The Strong Heart Water Study.

Many rural populations, including American Indian communities, that use private wells from groundwater for their source of drinking and cooking water are disproportionately exposed to elevated levels of arsenic. However, programs aimed at reducing arsenic in American Indian communities are limited. The Strong Heart Water Study (SHWS) is a randomized controlled trial aimed at reducing arsenic exposure among private well users in American Indian Northern Great Plains communities. The community-led SHWS program installed point-of-use (POU) arsenic filters in the kitchen sink of households, and health promoters delivered arsenic health communication programs. In this study we evaluated the efficacy of these POU arsenic filters in removing arsenic during the two-year installation period. Participants were randomized into two arms. In the first arm households received a POU arsenic filter, and 3 calls promoting filter use (SHWS mobile health (mHealth) & filter arm). The second arm received the same filter and phone calls, and 3 in-person home visits and 3 Facebook messages (SHWS intensive arm) for program delivery. Temporal variability in water arsenic concentrations from the main kitchen faucet was also evaluated. A total of 283 water samples were collected from 50 households with private wells from groundwater (139 filter and 144 kitchen faucet samples). Ninety-three percent of households followed after baseline had filter faucet water arsenic concentrations below the arsenic maximum contaminant level of 10 µg/L at the final visit during our 2 year study period with no difference between study arms (98 % in the intensive arm vs. 94 % in the mHealth & filter arm). No significant temporal variation in kitchen arsenic concentration was observed over the study period (intraclass correlation coefficient = 0.99). This study demonstrates that POU arsenic filters installed for the community participatory SHWS program were effective in reducing water arsenic concentration in study households in both arms, even with delivery of the POU arsenic filter and mHealth program only. Furthermore, we observed limited temporal variability of water arsenic concentrations from kitchen faucet samples collected over time from private wells in our study setting.

Urinary Zinc and Incident Type 2 Diabetes: Prospective Evidence From the Strong Heart Study.

OBJECTIVE: Hyperglycemia can increase urinary zinc excretion. We evaluated the association of higher urinary zinc level with new diagnosis of incident type 2 diabetes mellitus (T2DM) in adult populations with a high burden of T2DM from AZ, OK, and ND and SD. We also assessed the cross-sectional association of urinary zinc levels with prevalent prediabetes. RESEARCH DESIGN AND METHODS: We included 1,339 adults free of T2DM at baseline (1989-1991) followed through 1998-1999 in the Strong Heart Study (SHS) and 1,905 family members of SHS participants followed as part of the Strong Heart Family Study (SHFS) through 2006-2009. RESULTS: T2DM incidence was 14.7% (mean follow-up 6.6 years) in the SHS and 13.5% (mean follow-up 5.6 years) in the SHFS. After adjustment for sex, site, education, smoking status, BMI, and estimated glomerular filtration rate, the hazard ratio of T2DM in comparing 75th vs. 25th percentiles of urinary zinc distribution was 1.21 (95% CI 1.08, 1.36) in the SHS and 1.12 (0.96, 1.31) in the SHFS. These associations were attenuated but significant in the SHS after adjustment for HOMA of insulin resistance (HOMA-IR) score. With exclusion of participants with prediabetes at baseline, urinary zinc remained significantly associated with T2DM in the SHS. In cross-sectional analyses, prediabetes was associated with higher urinary zinc levels. CONCLUSIONS: Urinary zinc levels were associated with T2DM incidence and prediabetes prevalence even after adjustment for HOMA-IR in populations with a high burden of T2DM. These results highlight the importance of zinc metabolism in diabetes development.

An epigenome-wide study of DNA methylation profiles and lung function among American Indians in the Strong Heart Study.

BACKGROUND: Epigenetic modifications, including DNA methylation (DNAm), are often related to environmental exposures, and are increasingly recognized as key processes in the pathogenesis of chronic lung disease. American Indian communities have a high burden of lung disease compared to the national average. The objective of this study was to investigate the association of DNAm and lung function in the Strong Heart Study (SHS). We conducted a cross-sectional study of American Indian adults, 45-74 years of age who participated in the SHS. DNAm was measured using the Illumina Infinium Human MethylationEPIC platform at baseline (1989-1991). Lung function was measured via spirometry, including forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC), at visit 2 (1993-1995). Airflow limitation was defined as FEV1 < 70% predicted and FEV1/FVC < 0.7, restriction was defined as FEV1/FVC > 0.7 and FVC < 80% predicted, and normal spirometry was defined as FEV1/FVC > 0.7, FEV1 > 70% predicted, FVC > 80% predicted. We used elastic-net models to select relevant CpGs for lung function and spirometry-defined lung disease. We also conducted bioinformatic analyses to evaluate the biological plausibility of the findings. RESULTS: Among 1677 participants, 21.2% had spirometry-defined airflow limitation and 13.6% had spirometry-defined restrictive pattern lung function. Elastic-net models selected 1118 Differentially Methylated Positions (DMPs) as predictors of airflow limitation and 1385 for restrictive pattern lung function. A total of 12 DMPs overlapped between airflow limitation and restrictive pattern. EGFR, MAPK1 and PRPF8 genes were the most connected nodes in the protein-protein interaction network. Many of the DMPs targeted genes with biological roles related to lung function such as protein kinases. CONCLUSION: We found multiple differentially methylated CpG sites associated with chronic lung disease. These signals could contribute to better understand molecular mechanisms involved in lung disease, as assessed systemically, as well as to identify patterns that could be useful for diagnostic purposes. Further experimental and longitudinal studies are needed to assess whether DNA methylation has a causal role in lung disease.

Environmental-level exposure to metals and metal-mixtures associated with spirometry-defined lung disease in American Indian adults: Evidence from the Strong Heart Study.

BACKGROUND: American Indians have a higher burden of chronic lung disease compared to the US average. Several metals are known to induce chronic lung disease at high exposure levels; however, less is known about the role of environmental-level metal exposure. We investigated respiratory effects of exposure to single metals and metal-mixtures in American Indians who participated in the Strong Heart Study. METHODS: We included 2077 participants with data on 6 metals (As, Cd, Mo, Se, W, Zn) measured from baseline urine samples (1989-1991) and who underwent spirometry testing at follow-up (1993-1995). We used generalized linear regression to assess associations of single metals with spirometry-defined measures of airflow limitation and restrictive ventilatory pattern, and continuous spirometry. We used Bayesian Kernel Machine Regression to investigate the joint effects of the metal-mixture. Sensitivity analyses included stratifying by smoking status and diabetes. RESULTS: Participants were 40% male, with median age 55 years. 21% had spirometry-defined airflow limitation, and 14% had a restrictive ventilatory pattern. In individual metal analyses, Cd was associated with higher odds of airflow limitation and lower FEV1 and FEV1/FVC. Mo was associated with higher odds of restrictive ventilatory pattern and lower FVC. Metal-mixtures analyses confirmed these models. In smoking stratified analyses, the overall metal-mixture was linearly and positively associated with airflow limitation among non-smokers; Cd was the strongest contributor. For restrictive ventilatory pattern, the association with the overall metal-mixture was strong and linear among participants with diabetes and markedly attenuated among participants without diabetes. Among those with diabetes, Mo and Zn were the major contributors. CONCLUSIONS: Environmental-level exposure to several metals was associated with higher odds of spirometry-defined lung disease in an American Indian population. Exposure to multiple metals, including Cd and Mo, may have an under-recognized adverse role on the respiratory system.

Spatial relationship between well water arsenic and uranium in Northern Plains native lands.

Arsenic and uranium in unregulated private wells affect many rural populations across the US. The distribution of these contaminants in the private wells of most American Indian communities is poorly characterized, and seldom studied together. Here, we evaluate the association between drinking water arsenic and uranium levels in wells (n = 441) from three tribal regions in North Dakota and South Dakota participating in the Strong Heart Water Study. Groundwater contamination was extensive; 29% and 7% of wells exceeded maximum contaminant levels for arsenic and uranium respectively. 81% of wells had both arsenic and uranium concentrations at one-tenth of their human-health benchmark (arsenic, 1 µg/L; uranium 3 µg/L). Well arsenic and uranium concentrations were uncorrelated (rs = 0.06); however, there appeared to be a spatial correlation of wells co-contaminated by arsenic and uranium associated with flow along a geologic contact. These findings indicate the importance of measuring multiple metals in well water, and to understand underlying hydrogeological conditions. The underlying mechanisms for the prevalence of arsenic and uranium across Northern Plains Tribal Lands in the US, and in particular the occurrence of both elevated arsenic and uranium in drinking water wells in this region, demands further study.

COVID-19 as Eco-Pandemic Injustice: Opportunities for Collective and Antiracist Approaches to Environmental Health.

The COVID-19 pandemic has coincided with a powerful upsurge in antiracist activism in the United States, linking many forms and consequences of racism to public and environmental health. This commentary develops the concept of eco-pandemic injustice to explain interrelationships between the pandemic and socioecological systems, demonstrating how COVID-19 both reveals and deepens structural inequalities that form along lines of environmental health. Using Pellow's critical environmental justice theory, we examine how the crisis has made more visible and exacerbated links between racism, poverty, and health while providing opportunities to enact change through collective embodied health movements. We describe new collaborations and the potential for meaningful opportunities at the intersections between health, antiracist, environmental, and political movements that are advocating for the types of transformational change described by critical environmental justice.

Correction to: Low-moderate arsenic exposure and respiratory health in American Indian communities in the Strong Heart Study.

The original version of this article [1], published on 28 November 2019, contained incorrect title. In this Correction the affected part of the article is shown.

Lung Function and Respiratory Symptoms after Tuberculosis in an American Indian Population. The Strong Heart Study.

Rationale: Permanent lung function impairment after active tuberculosis infection is relatively common. It remains unclear which spirometric pattern is most prevalent after tuberculosis.Objectives: Our objective was to elucidate the impact of active tuberculosis survival on lung health in the Strong Heart Study (SHS), a population of American Indians historically highly impacted by tuberculosis. As arsenic exposure has also been related to lung function in the SHS, we also assessed the joint effect between arsenic exposure and past active tuberculosis.Methods: The SHS is an ongoing population-based, prospective study of cardiovascular disease and its risk factors in American Indian adults. This study uses tuberculosis data and spirometry data from the Visit 2 examination (1993-1995). Prior active tuberculosis was ascertained by a review of medical records. Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and FEV1/FVC were measured by spirometry. An additional analysis was conducted to evaluate the potential association between active tuberculosis and arsenic exposure.Results: A history of active tuberculosis was associated with reduced percent predicted FVC and FEV1, an increased odds of airflow obstruction (odds ratio = 1.45, 95% confidence interval = 1.08-1.95), and spirometric restrictive pattern (odds ratio = 1.73, 95% confidence interval = 1.24-2.40). These associations persisted after adjustment for diabetes and other risk factors, including smoking. We also observed the presence of cough, phlegm, and exertional dyspnea after a history of active tuberculosis. In the additional analysis, increasing urinary arsenic concentrations were associated with decreasing lung function in those with a history of active tuberculosis, but a reduced odds of active tuberculosis was found with elevated arsenic.Conclusions: Our findings support existing knowledge that a history of active tuberculosis is a risk factor for long-term respiratory impairment. Arsenic exposure, although inversely associated with prior active tuberculosis, was associated with a further decrease in lung function among those with a prior active tuberculosis history. The possible interaction between arsenic and tuberculosis, as well as the reduced odds of tuberculosis associated with arsenic exposure, warrants further investigation, as many populations at risk of developing active tuberculosis are also exposed to arsenic-contaminated water.

Low-moderate arsenic exposure and respiratory in American Indian communities in the Strong Heart Study.

BACKGROUND: Arsenic exposure through drinking water is an established lung carcinogen. Evidence on non-malignant lung outcomes is less conclusive and suggests arsenic is associated with lower lung function. Studies examining low-moderate arsenic (< 50 µg/L), the level relevant for most populations, are limited. We evaluated the association of arsenic exposure with respiratory health in American Indians from the Northern Plains, the Southern Plains and the Southwest United States, communities with environmental exposure to inorganic arsenic through drinking water. METHODS: The Strong Heart Study is a prospective study of American Indian adults. This analysis used urinary arsenic measurements at baseline (1989-1991) and spirometry at Visit 2 (1993-1995) from 2132 participants to evaluate associations of arsenic exposure with airflow obstruction, restrictive pattern, self-reported respiratory disease, and symptoms. RESULTS: Airflow obstruction was present in 21.5% and restrictive pattern was present in 14.4%. The odds ratio (95% confidence interval) for obstruction and restrictive patterns, based on the fixed ratio definition, comparing the 75th to 25th percentile of arsenic, was 1.17 (0.99, 1.38) and 1.27 (1.01, 1.60), respectively, after adjustments, and 1.28 (1.02, 1.60) and 1.33 (0.90, 1.50), respectively, based on the lower limit of normal definition. Arsenic was associated with lower percent predicted FEV1 and FVC, self-reported emphysema and stopping for breath. CONCLUSION: Low-moderate arsenic exposure was positively associated with restrictive pattern, airflow obstruction, lower lung function, self-reported emphysema and stopping for breath, independent of smoking and other lung disease risk factors. Findings suggest that low-moderate arsenic exposure may contribute to restrictive lung disease.

Arsenic in groundwater in private wells in rural North Dakota and South Dakota: Water quality assessment for an intervention trial.

Elevated exposure to arsenic disproportionately affects populations relying on private well water in the United States (US). This includes many American Indian (AI) communities where naturally occurring arsenic is often above 10 µg/L, the current US Environmental Protection Agency safety standard. The Strong Heart Water Study is a randomized controlled trial aiming to reduce arsenic exposure to private well water users in AI communities in North Dakota and South Dakota. In preparation for this intervention, 371 households were included in a community water arsenic testing program to identify households with arsenic ≥10 µg/L by inductively coupled plasma mass spectrometry (ICP-MS). Arsenic ≥10 µg/L was found in 97/371 (26.1%) households; median water arsenic concentration was 6.3 µg/L, ranging from <1-198 µg/L. Silica was identified as a water quality parameter that could impact the efficacy of arsenic removal devices to be installed. A low-range field rapid arsenic testing kit evaluated in a small number of households was found to have low accuracy; therefore, not an option for the screening of affected households in this setting. In a pilot study of the effectiveness of a point-of-use adsorptive media water filtration device for arsenic removal, all devices installed removed arsenic below 1 µg/L at both installation and 9 months post-installation. This study identified a relatively high burden of arsenic in AI study communities as well as an effective water filtration device to reduce arsenic in these communities. The long-term efficacy of a community based arsenic mitigation program in reducing arsenic exposure and preventing arsenic related disease is being tested as part of the Strong Heart Water Study.

The Strong Heart Water Study: Informing and designing a multi-level intervention to reduce arsenic exposure among private well users in Great Plains Indian Nations.

Elevated arsenic exposure from drinking water is associated with an increased risk of cardiovascular disease, diabetes, kidney disease, and skin, lung, and bladder cancer. Arsenic contamination in groundwater supplies disproportionately affects rural populations using private wells. Arsenic mitigation programs for American Indian communities are limited. There is an urgent need for targeted approaches to reduce arsenic exposure for at-risk communities using private wells. Formative research was conducted to inform and design a community-based arsenic mitigation intervention for Lakota and Dakota Nations in the Great Plains Area of the United States, where, in some communities, one-quarter of private wells are estimated to have elevated arsenic. Formative research included semi-structured interviews, a community workshop, intervention-planning workshops, and a pilot study of the developed intervention. Community members prioritize aesthetic qualities of water (e.g. taste, color), safety, and other situational factors (e.g. cost) when considering their drinking and cooking water. Although water safety is a concern, awareness and concern for arsenic vary substantially within communities. To reduce arsenic exposure, community members recommended communication of water test results, home visits for intervention delivery, and reminders to use arsenic-safe water. Findings informed the development of an intervention to prevent arsenic exposure through drinking water and cooking, including health promotion messages and household items to facilitate use of an arsenic removal device (e.g. tankards to store filtered water). The pilot study indicated promising acceptability and operability of the developed intervention. This research provides a model for the development of environmental health interventions in partnership with American Indian and other private well-using communities.

A Meta-analysis of Arsenic Exposure and Lung Function: Is There Evidence of Restrictive or Obstructive Lung Disease?

PURPOSE OF REVIEW: Hundreds of millions of people worldwide are exposed to arsenic via contaminated water. The goal of this study was to identify whether arsenic-associated lung function deficits resemble obstructive- or restrictive-like lung disease, in order to help illuminate a mechanistic pathway and identify at-risk populations. RECENT FINDINGS: We recently published a qualitative systematic review outlining the body of research on arsenic and non-malignant respiratory outcomes. Evidence from several populations, at different life stages, and at different levels of exposure showed consistent associations of arsenic exposure with chronic lung disease mortality, respiratory symptoms, and lower lung function levels. The published review, however, only conducted a broad qualitative description of the published studies without considering specific spirometry patterns, without conducting a meta-analysis, and without evaluating the dose-response relationship. We searched PubMed and Embase for studies on environmental arsenic exposure and lung function. We performed a meta-analysis using inverse-variance-weighted random effects models to summarize adjusted effect estimates for arsenic and forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and FEV1/FVC ratio. Across nine studies, median water arsenic levels ranged from 23 to 860 µg/L. The pooled estimated mean difference (MD) comparing the highest category of arsenic exposure (ranging from > 11 to > 800 µg/L) versus the lowest (ranging from < 10 to < 100 µg/L) for each study for FEV1 was - 42 mL (95% confidence interval (CI) - 70, - 16) and for FVC was - 50 mL (95% CI - 63, - 37). Three studies reported effect estimates for FEV1/FVC, for which there was no evidence of an association; the pooled estimated MD was 0.01 (95% CI - 0.005, 0.024). This review supports that arsenic is associated with restrictive impairments based on inverse associations between arsenic and FEV1 and FVC, but not with FEV1/FVC. Future studies should confirm whether low-level arsenic exposure is a restrictive lung disease risk factor in order to identify at-risk populations in the USA.

Popular epidemiology and "fracking": citizens' concerns regarding the economic, environmental, health and social impacts of unconventional natural gas drilling operations.

Pennsylvania sits atop the Marcellus Shale, a reservoir of natural gas that was untapped until the 2004 introduction of unconventional natural gas drilling operations (UNGDO) in the state. Colloquially known as fracking, UNGDO is a controversial process that employs large volumes of water to fracture the shale and capture gas; it has become a multi-billion dollar industry in Pennsylvania. We analyzed letters to the editor of the most widely circulated local newspaper in the most heavily drilled county in Pennsylvania (Bradford County) in order to characterize residents' concerns and their involvement in popular epidemiology--the process by which citizens investigate risks associated with a perceived environmental threat. We reviewed 215 letters to the editor that referenced natural gas operations and were published by The Daily Review between January 1, 2008 and June 8, 2013. We used NVivo 10 to code and analyze letters and identify major themes. Nvivo is qualitative data analysis software (http://www.qsrinternational.com/products_nvivo.aspx) that allows researchers to code and analyze "unstructured" data, including text files of any type (e.g., interview transcripts, news articles, letters, archival materials) as well as photographs and videos. Nvivo can be used to classify, sort, query, comment on, and share data across a research group. Letters demonstrated citizen engagement in beginning and intermediate stages of lay epidemiology, as well as discord and stress regarding four main issues: socio-economic impacts, perceived threats to water, population growth and implications, and changes to the rural landscape. Residents called for stronger scientific evidence and a balance of economic development and health and environmental protections. Citizens' distress regarding UNGDO appeared to be exacerbated by a dearth of information to guide economic growth and health, environmental, and social concerns. This analysis proposes locally informed questions to guide future surveillance and research.

Field survey of health perception and complaints of Pennsylvania residents in the Marcellus Shale region.

Pennsylvania Marcellus Shale region residents have reported medical symptoms they believe are related to nearby Unconventional Natural Gas Development (UNGD). Associations between medical symptoms and UNGD have been minimally explored. The objective of this descriptive study is to explore whether shale region Pennsylvania residents perceive UNGD as a health concern and whether they attribute health symptoms to UNGD exposures. A questionnaire was administered to adult volunteers with medical complaints in a primary-care medical office in a county where UNGD was present. Participants were asked whether they were concerned about health effects from UNGD, and whether they attributed current symptoms to UNGD or to some other environmental exposure. There were 72 respondents; 22% perceived UNGD as a health concern and 13% attributed medical symptoms to UNGD exposures. Overall, 42% attributed one or more of their medical symptoms to environmental causes, of which UNGD was the most frequent. A medical record review conducted on six participants who attributed their medical symptoms to UNGD revealed that only one of these records documented both the symptoms in question and the attribution to UNGD. The results of this pilot study suggest that there is substantial concern about adverse health effects of UNGD among Pennsylvania Marcellus Shale residents, and that these concerns may not be adequately represented in medical records. Further efforts to determine the relationship between UNGD and health are recommended in order to address community concerns.

Occupational chemical exposures among cosmetologists: risk of reproductive disorders.

More research is needed to understand possible occupational reproductive risks for cosmetologists, specifically hairdressers and nail technicians, two occupations that often share workspace and exposure to hair dyes and nail polish. Cosmetologists are predominantly females of reproductive age; thus, they may be at higher risk for the effects of exposure to reproductive toxins. The purpose of this article is to inform nurses and public health professionals about occupational exposures for cosmetologists and discuss interventions to reduce the risks of reproductive disorders among susceptible worker populations.