- Email: [email protected]
Factors affecting environmental awareness among Head Start families in Mississippi
Factors Affecting Environmental Awareness Among Head Start Families in Mississippi Benjamin L. Preston, PhD, Rueben C. Warren, DDS, MPH, DrPH, Peter Stewart, PhD Background: Socioeconomic and racial/ethnic disparities in health status in the United States may be attributed in part to environmental injustice and differential exposure to environmental hazards among low-income and/or minority populations. However, the environmental justice movement has historically focused on equity in the siting of point-source polluting facilities, giving little attention to environmental hazards and environmental awareness at the level of the individual household. Methods:
Heads of 763 low-income households participating in Head Start programs in 20 counties of the Mississippi Delta region were surveyed regarding their education, the physical environment of their home and workplace, sources of food and water, awareness of local polluting sites/facilities, knowledge of government agencies, and behaviors that may affect their health or impact their local environment. Survey results were compared to demographic, socioeconomic, and environmental quality indicators.
Results:
Significant associations existed between both education and race/ethnicity and the responses of survey participants. Being African American was more commonly associated with poor quality-of-life indicators such as renting substandard older homes and living in close proximity to areas of unfavorable watershed quality. Higher education was more commonly and positively associated with indicators of heightened environmental awareness and increased political empowerment. No association was observed between race/ ethnicity and the prevalence of polluting facilities. However, a significant association existed between race/ethnicity and indicators of environmental quality/integrity.
Conclusions: Environmental health education interventions that target individual households may be a useful mechanism for increasing the access of low-income communities to government health resources and reducing adverse health effects from the environment. However, racial/ethnic disparities in education and health remain an important consideration. Medical Subject Headings (MeSH): environmental health, health education, poverty, social justice (Am J Prev Med 2000;19(3):174 –179) © 2000 American Journal of Preventive Medicine
D
uring the past century, significant advances have been made toward improving the health, longevity, and quality of life of individuals in the United States.1 However, there are still numerous populations within the United States whose health and quality of life lag behind that of the general population and, in some cases, are comparable to developing countries.2,3 These populations are often comprised of low-income and/or minority racial/ethnic groups, creFrom the Carolina Environmental Program, University of North Carolina-Chapel Hill (Preston), Chapel Hill, North Carolina; Office of Urban Affairs, Agency for Toxic Substances and Disease Registry, U.S. Department of Health and Human Services (Warren), Atlanta, Georgia; and Natural Science and Environment Education Programs, Inc. (Stewart), Edwards, Mississippi Address correspondence and reprint requests to: Rueben C. Warren, DDS, MPH, DrPH, U.S. Department of Health and Human Services, Office of Urban Affairs, Agency for Toxic Substances and Disease Registry, 1600 Clifton Road NE, Mailstop E-28, Atlanta, GA 30333. E-mail: [email protected].
174
ating a socioeconomic and racial/ethnic disparity in health.4 –7 Although this disparity is attributed in part to differences in infant mortality, heart disease, cancer, cirrhosis, diabetes, and injury among racial/ethnic and socioeconomic groups, public health professionals have yet to account for a significant portion of the health disparity.4,8 Increasing evidence suggests that disproportionate risk of exposure to environmental hazards among low-income and minority groups may contribute to the disparity in health. One review of 30 studies of environmental risks identified racial/ethnic or socioeconomic disparities in ⬎80% of cases.9 For example, landfills and other hazardous waste storage facilities have historically been constructed in communities that are predominantly low-income and minority.10 Similarly, facilities that release contaminants included in the U.S. Environmental Protection Agency’s (EPA) Toxic Release Inventory (TRI) are concentrated in low-income, minority communities as well.11–13
Am J Prev Med 2000;19(3) 0749-3797/00/$–see front matter © 2000 American Journal of Preventive Medicine • Published by Elsevier Science Inc. PII S0749-3797(00)00195-1
In 1994, President Clinton issued Executive Order 12898, requiring federal agencies to consider environmental justice issues in their activities to help ensure that low-income and minority communities are not disproportionately exposed to environmental risks. Executive Order 12898 was intended to address a broad range of issues related to the environment, including economics, environmental regulation and planning, health effects, and environmental education. However, many environmental justice debates continue to center on past, present, and future siting of polluting and/or potentially hazardous facilities. Although these are important public policy considerations, environmental threats may result from the circumstances at the level of the individual household. For example, lead paint, pesticides, and contaminated drinking water are frequent environmental concerns, although the immediately affected population may consist of a limited number of individuals. Therefore, a hierarchical approach to environmental justice policy is necessary to implement interventions at the national, state, regional, community, and household levels. The state of Mississippi has historically been an area challenged by widespread economic depression, poverty, poor health status, and undereducation.14 These problems are further exacerbated by real or perceived environmental contamination and degradation that occur disproportionately in minority communities.15 As a result, a large portion of the state has been included in the Mississippi Delta Project (MDP), an initiative to address the environmental issues of the Mississippi Delta region and their relationship to human health and quality of life.14 The current study was designed to assess the influences of community urbanization, income, racial/ethnic composition, and education on environmental awareness and exposure to potential environmental hazards among Head Start families in Mississippi. A total of 763 low-income, female heads-ofhousehold were surveyed for their knowledge on environmental issues and daily behaviors that may affect the health of their families. In addition, a qualitative assessment of the environmental quality within the communities of survey respondents was performed. Subsequently, data on population size, racial/ethnic composition, and socioeconomic indicators were collected to test for associations between these factors and the responses of survey participants and the environmental quality of their communities.
Materials and Methods Data regarding environmental awareness and behaviors were collected through the administration of a 77-item survey, developed by Mississippi Action for Progress Inc. (MAP), and sent to female-headed households with children (aged 2 to 5) participating in the Head Start programs in the 20 counties of the MAP service area (Alcorn, Calhoun, Chickasaw, Claiborne, Franklin, Hancock, Itawamba, Lauderdale, Leflore,
Lincoln, Neshoba, Pearl River, Perry, Prentiss, Scott, Tippah, Tishomingo, Union, Warren, and Yalobusha). A total of 804 Head Start households was selected at random out of the approximately 5000 households participating in MAP Head Start programs. The head of each participating household was asked to complete a written survey containing questions regarding her age, race, and education, the physical environment of the home and workplace, sources of food and drinking water, awareness of local waste sites or polluting facilities, and familiarity with government agencies addressing environment and health issues. All participants were asked to read and sign consent forms containing a description of the survey and the environment health project. Survey administrators attended a two-day course on understanding and administering the survey prior to its use and were available to answer questions about the survey while it was being completed. A total of 763 (95%) participants completed the survey, representing 2974 children and adults. The average time for completion of the survey was 90 minutes. Chi-square analysis (␣⫽0.05) was used to assess whether the responses of survey participants to a subset of survey questions varied significantly with race/ethnicity (Caucasian, African American, or other) or education (high school grad/GED or less, or education beyond high school) under the null hypothesis of no significant difference in responses among racial/ethnic and educational categories. Numerous environmental quality indicators were obtained for the 20 counties in the MAP service area. All data on environmental quality were obtained through various databases maintained at the U.S. Environmental Protection Agency’s (EPA) Internet website (http://www.epa.gov). The number of polluting facilities and hazardous waste sites regulated by the EPA for each county at the time the study began was obtained from the EPA’s Envirofacts databases. These sites included facilities receiving permits under the National Pollution Discharge Elimination System (NPDES), facilities listed under the Aeromatic Information Retrieval System (AIRS), facilities listed under the Toxic Release Inventory, facilities regulated by the Resource Conservation and Recovery Act (RCRA), and National Priority List (NPL) sites regulated by the Comprehensive Environmental Response Compensation Liability and Recovery Act (CERCLA). The 1998 Pollution Standards Index (PSI) for air quality was obtained for each county from EPA’s Center for Environmental Information and Statistics (CEIS). Possible PSI values were good, moderate, unhealthful, very unhealthful, or hazardous, indicating relative risk of adverse effects to humans. Counties were checked for compliance with the Clean Air Act (CAA) through EPA’s Environmental Indicators database. All public drinking water providers in each county in 1998 and their 10-year violation history were identified through the EPA’s Safe Drinking Water Information System (SDWIS). Major watersheds within each county were identified through EPA’s CEIS. The index of watershed indicators (IWI) score (1996), the percentage of surveyed watershed miles supporting statedesignated usage (1996), the number of fish advisories issued (1997), and the principal contaminants were obtained for each watershed in each county (1996). IWI scores ranged from 1 to 6, with 1 indicating high quality and 6 indicating low quality. Results for all watersheds within a county were averaged to obtain an overall indicator of county watershed health.
Am J Prev Med 2000;19(3)
175
Table 1. Frequency of responses (%) to survey inquiries, stratified by race/ethnicitya Inquiry
Total (%) (Nⴝ763)b
Caucasians (%) (nⴝ169)b
African Americans (%) (nⴝ561)b
Other (%) (nⴝ19)b
Education beyond high school Own vs rent home Reside in a city/town Obtain food from a personal farm Eat game caught by household member Reported landfill in county Reported chemical plant in county Dispose of automobile antifreeze improperly Smoker in household Problems with insects in home Problems with rodents in home
51 53 48 10 73 35 21 75 30 37 15
54 66 32 20 82 44 15 76 41 22 9
48 48 53 8 64 33 23 54 26 36 17
79 50 53 5 53 22 28 91 53 13 13
p ⬍.05 ⬍.001 ⬍.0001 ⬍.001 ⬍.01 ⬍.05 ⬍.05 ⬍.0001 ⬍.001 ⬍.01 ⬍.05
a
Only statistically significant results are shown. Number of individuals in each category completing the survey. However, survey respondents did not necessarily respond to all inquiries.
b
Demographic data—including population size, race/ethnicity, education, per capita income, and per capita sales— were collected for each of the 20 counties in the MAP service area. Data were obtained from the U.S. Census Bureau through the Government Information Sharing Project at Oregon State University. The most recent year for which data were available for population size and racial/ethnic composition was 1997. The most recent data year available for education, income, and sales was 1995. Associations among county demographic characteristics, responses of survey participants, and county environmental quality indicators were assessed by calculating correlation coefficients (␣⫽0.05, df⫽18).
Results Responses to MAP Survey Most survey respondents (75%) were African American, while 23% were Caucasian, and the remaining 2% were of other races/ethnicities. One percent of respondents were aged 15 to 18; 52%, 19 to 29; 30%, 30 to 39; and 17%, ⱖ40. Household size ranged from 1 to 13, with a mean and median size of 4. When asked about the highest level of education completed, 4% of respondents completed elementary school, 51% completed high school or received a GED, 5% attended a vocational school, 29% attended some college, 7% graduated from college, and 4% pursued graduate studies. For the purpose of statistical analyses, respondent education was pooled into two categories of similar sample size: (1) high school education or less, and (2) education beyond high school. Significant associations existed between both the education and race/ethnicity of respondents and the frequency of responses to a number of survey inquiries (Tables 1, 2, 3).
Environmental Indicators A total of 1719 EPA-regulated, polluting facilities/sites was identified in the 20 counties of the MAP service area. The number of facilities per county ranged from 27 to 242 with a mean of 86. No NPL sites were 176
identified in any of the 20 counties. All 20 counties were in compliance with the Clean Air Act, and the PSI for air quality was “moderate” for all 20 counties, indicating few or no health effects related to air pollution for the general population. A total of 228 public drinking water providers was identified, ranging from 7 to 30 per county, with a mean of 11. These drinking water providers reported a total of 686 violations between 1988 and 1998, ranging from 2 to 86 per county with a mean of 34. These violations resulted from exceeding permissible contaminant levels in drinking water or problems in monitoring contaminant levels or facility maintenance. The vast majority of these violations were related to coliform contamination, although a few were related to violation of lead/copper criteria. A total of 41 watersheds were identified, with a mean of 4 per county; however, a single watershed could traverse multiple counties. The median IWI score for watersheds in the 20 counties was 3 (“less serious, low vulnerability”), indicating moderate problems with con-
Table 2. Frequency of responses (%) to survey inquiries, stratified by educationa Inquiry Own vs rent home Know causes of food poisoning Reported chemical plant in county Reported incinerator in county Know agency to contact re: surface water problems Know agency to contact re: drinking water problems Know whether or not drinking water is monitored a
High Total (%) school (%) school (%) b b (Nⴝ763) (nⴝ376) (nⴝ387)b
p
53 74
48 70
58 78
⬍.01 ⬍.05
21
18
25
⬍.05
16
18
15
⬍.05
30
21
38
⬍.01
58
49
62
⬍.0001
35
30
39
⬍.05
Only statistically significant results are shown. Number of individuals in each category completing the survey. However, survey respondents did not necessarily respond to all inquiries. b
American Journal of Preventive Medicine, Volume 19, Number 3
Table 3. Percentage of survey respondents reporting familiarity with specific environmental and health agencies, stratified by race/ethnicity or education
Agency U.S. Environmental Protection Agency U.S. Department of Health and Human Services Centers for Disease Control and Prevention U.S. Department of the Interior U.S. Department of Agriculture Mississippi State Department of Health Mississippi Department of Environmental Quality Mississippi Wildlife, Fisheries, and Parks Department Mississippi Regional Poison Control Facility County Health Department
African Total (%) Caucasians (%) American (%) Other (%) (nⴝ561) (nⴝ19)a p (Nⴝ763)a (nⴝ169)a
>High
22
28
21
21
NS
16
27
⬍.001
37
36
32
32
NS
33
41
⬍.05
25
30
26
26
NS
18
32
⬍.0001
6 23 38
8 22 37
11 32 42
11 32 42
NS NS NS
5 17 32
8 29 44
NS ⬍.0001 ⬍.001
11
11
16
16
NS
8
14
⬍.01
26
23
48
48
NS
22
30
⬍.05
20
27
32
32
NS
16
24
⬍.01
40
38
53
53
⬍.05 35
46
⬍.01
p
a
Number of individuals from each category completing the survey. However, survey respondents did not necessarily respond to all inquiries. NS, not significant
tamination and/or human impacts. However, nine counties had mean IWI scores of 4 or 5, indicating more serious contamination/impacts. The mean percentage of surveyed miles of surface water meeting designated usage ranged from 10% to 71% for the 20 counties, with an overall mean of 43%. A total of 24 fish advisories were issued or in effect in 1997 across the 20 counties. The most common pollutants in rivers and streams were pesticides, nutrients, siltation, organic enrichment, and pathogens (bacterial/viral).
County Demographics and Socioeconomic Indicators Data from the U.S. Census Bureau indicated that the mean 1997 population size for the 20 counties in the MAP service area was 27,559 — of which 69% were Caucasian; 29%, African American; 1%, Native American; 0.2%, Asian/Pacific Islanders; and 0.8%, Hispanic. On average, 48% of the county populations were male. In 1995, approximately 59% of adults aged ⱖ25 had graduated from high school and 11% had graduated from college. Mean 1995 per capita income and per capita retail sales were $13,832 and $5041, respectively. Large variations existed between counties with respect to size, racial/ethnic composition, education, and income. In addition, significant correlations were found among demographic/socioeconomic indicators, the responses of survey participants, and indicators of environmental quality (Table 4).
Discussion In addition to the traditional concerns of race/ethnicity in environmental justice, the results of this study
suggest that differences in education among groups may be an additional concern in addressing environmental health issues. Survey respondents who had education beyond high school were consistently more likely to be familiar with government agencies with responsibilities in the area of health and the environment (Table 3). Respondents tended to be more familiar with health agencies (e.g., the U.S. Department of Health and Human Services, the Mississippi State Health Department, and county health departments) than they were with agencies specializing in environmental issues. This disparity may result from the dependence of this population on public health agencies/ facilities, particularly local health departments, for basic health care needs.16 –19 In addition, although 35% of respondents reported a landfill within their county, 1995 data from EPA’s Office of Solid Waste indicates that only three regulated municipal landfills exist within the MAP service area (in Lauderdale, Pearl River, and Scott counties). This may reflect a false perception of environmental hazards among this population and/or a general lack of familiarity with local polluting facilities. Although the education of survey participants did not seem to influence their sources of food or water, participants from counties with higher proportions of high school and college graduates were more likely to be connected to public water providers and less likely to obtain their food from a personal farm or utilize wild game as a food source. Utilizing personal farms, hunting, and fishing for food sources may be associated with increased risk of food-borne exposure to contaminants. For example, 12 of the 20 counties in the MAP service Am J Prev Med 2000;19(3)
177
Table 4. Results of correlation analyses testing associations between county demographic characteristics, environmental quality indicators, and responses to survey inquiries for 20 counties in the MAP service areaa Independent variable
Dependent variable
R
County population size
Per capita income Per capita sales Percentage of high school graduates Percentage of college graduates Percentage of respondents residing in city/town
0.63 0.77 0.54 0.68 0.46
⬍0.01 ⬍0.01 ⬍0.05 ⬍0.01 ⬍0.05
County per capita income
Per capita sales Number of EPA sites in county Percentage of respondents who consume game caught by household member
0.73 0.7 ⫺0.55
⬍0.01 ⬍0.01 ⬍0.05
Percentage of high school graduates
Percentage of college graduates Number of EPA sites in county Percentage of households using well water as source of drinking water Percentage of households obtaining food from personal farm Percentage of households with farm worker Percentage of households with factory worker
0.55 0.58 0.49
⬍0.05 ⬍0.01 ⬍0.05
⫺0.49 ⫺0.62 ⫺0.62
⬍0.05 ⬍0.01 ⬍0.01
0.46 0.58 0.56 0.52 0.46 0.58
⬍0.05 ⬍0.01 ⬍0.01 ⬍0.05 ⬍0.05 ⬍0.01
⫺0.51
⬍0.05
0.66 ⫺0.59 0.5 ⫺0.47 0.49
⬍0.01 ⬍0.01 ⬍0.05 ⬍0.05 ⬍0.05
Percentage of college graduates
Percentage of minorities in population
Per capita sales Percentage of minorities in population Number of EPA sites in county Percentage of households in a city/town Percentage of households with home ⬎25 years old Percentage of households using well water as source of drinking water Percentage of households that consume game caught by household member Index of watershed indicators score Percentage of surface waters meeting designated usage Home ⬎25 years old Know causes of food poisoning Problems with insects in home
p
a Only statistically significant results are shown. MAP, Mississippi Action for Progress, Inc.; EPA, U.S. Environmental Protection Agency
area had at least one fish advisory in 1997. Thus, communities with higher levels of education may be more likely to select low-risk sources of food such as commercial distributors. The predominant factors determining the education level of counties appeared to be population size, which was also associated with income. Thus, individuals from more populated areas are predicted to be better educated and wealthier on average, which is likely a function of diversity in and access to educational and employment opportunities. This is supported by the observation that respondents from counties with higher proportions of high school graduates also reported fewer household members working in factory/manufacturing or agricultural jobs (Table 4), which are often associated with more health impacts than other areas of employment.20 –22 Although education may be an important factor affecting environmental risk, race/ethnicity did influence environmental quality and respondent awareness. The percentage of survey respondents who had education beyond high school was significantly higher among Caucasians than African Americans (Table 1), reflecting the national racial/ethnic 178
disparity in education and socioeconomic status.23–25 Minority survey respondents were less likely to own their own homes, reside in rural areas, or smoke, and African Americans were more likely to report problems with both insect and rodent infestations than Caucasians. Similarly, respondents from counties with higher proportions of minorities in the population were more likely to report residing in a house constructed ⬎25 years ago or report problems with both insect and rodent infestations (Table 4). In addition, there was a highly significant correlation between the minority composition of counties and indicators of watershed quality. Lastly, the fact that minorities were more likely to report the presence of both landfills and chemical plants within their communities (Table 1) suggests that minorities may have greater environmental concerns and/or perceptions of injustice than Caucasian communities.26 –29 It should be noted that this study has several limitations. First, we cannot exclude the possibility of recall bias or error in the self-reported responses of survey participants. Second, environmental indicators, such as the number of polluting facilities or watershed quality
American Journal of Preventive Medicine, Volume 19, Number 3
are not indicators of exposure; as a result, they are not necessarily associated with risk. Third, analysis at the county level may not be sensitive enough to detect more localized interactions between demographics and environmental quality. Fourth, although correlation analyses (Table 4) indicated that significant associations existed among numerous variables, no definitive conclusions regarding the cause for these associations can be made.30 Lastly, given the absence of controls, the fact that surveyed households were participating in a program targeting families with specific characteristics and the over-representation of African Americans in the survey population, it seems unlikely that the survey population was representative of the general population of Mississippi or the United States. Education stands out as an important factor governing individual behaviors, economic opportunity, and access to resources for this population. Education has also been demonstrated to have significant impact on personal health and quality of life.31–34 Promoting health education through such programs as Head Start may help mitigate the adverse effects of socioeconomic and environmental challenges to health. However, race/ethnicity remains an important consideration and continued efforts should be directed at reducing racial disparities in health, education, and involvement in environmental decision making. In addition, improving the access of low-income/minority communities to environmental health education and resources may increase their political involvement, thereby bringing attention to existing environmental problems and preventing future racial/ethnic or socioeconomic disparities in environmental management.35–38 The benefits of urban life—access to education, health care, reliable sources of food and water, and nonindustrial or nonagricultural jobs—suggest that the promotion of economic development and urbanization may improve the health and quality of life for individuals in the predominantly rural state of Mississippi. The authors would like to acknowledge the assistance of the Regional Research Center for Minority Health, Morehouse School of Medicine, and Mississippi Action for Progress, Inc., in conducting this study.
References 1. Erhardt CL, Berlin JE. Mortality and morbidity in the United States. Cambridge, MA: Harvard University Press, 1974. 2. McCord C, Freeman HP. Excess mortality in Harlem. N Engl J Med 1990 322:173–7. 3. Fullilove RE, Aidala AA, Bassett MT, et al. Risk factors for excess mortality in Harlem: findings from the Harlem Household Survey. Am J Prev Med 1999;16(suppl 3):22– 8. 4. U.S. Department of Health and Human Services. Report of the Secretary’s Task Force on Black & Minority Health. Washington: Government Printing Office, 1985. 5. Freeman HP. Poverty, race, racism, and survival. Ann Epidemiol 1993;3: 145–9. 6. Mason JM. Understanding the disparities in morbidity and mortality among racial and ethnic groups in the United States. Ann Epidemiol 1993;3:120 – 4.
7. Warren RC. The morbidity/mortality gap: what is the problem? Ann Epidemiol 1993;3:127–9. 8. Otten M, Marks J, Siber R, Teutsch S, Williamson D. The effect of known risk factors on the excess mortality of black adults in the United States. JAMA 1990;263:845–50. 9. Allen D, Lester J, Hill K. Prejudice, profits, and power: assessing the eco-racism thesis at the county level. Paper presented at the Western Political Science Association Annual Meeting, Portland, OR, March 16 –18, 1995. 10. Bullard R. Dumping in Dixie: race, class, and environmental quality. Boulder, CO: Westview, 1990. 11. Burke L. Race and environmental equity: a geographic analysis in Los Angeles. Geo Information Info Sys 1994;October:44 –50. 12. Cutter S. The burdens of toxic risks: are they fair? Business Econ Rev 1994;40:101–13. 13. Pollock P, Vittas ME. Who bears the burdens of environmental pollution? Race, ethnicity, and environmental equity in Florida. Soc Sci Q 1995;76: 294 –310. 14. Nathan VR, Gatebuke J, Knuckles M. Mississippi Delta Project: health and environment. Nashville, TN: Division of Environmental Health, Meharry Medical College, 1995. 15. Mielke HW. The urban environment and children’s health: soils as an integrator of lead, zinc, and cadmium in New Orleans, Louisiana, USA. Environ Res 1999;81:117–29. 16. Kleinman JC, Gold M, Makuc D. Use of ambulatory medical care by the poor: another look at equity. Med Care 1981;19:1011–29. 17. Miller CA, Brainard MP, Brown ML, Kotch JB, Moos MK. Role of local health departments in the delivery of ambulatory care. Am J Public Health 1981;71:15–29. 18. Newacheck PW, Butler LH. Patterns of physician use among low-income, chronically ill persons. Med Care 1983;21:981–9. 19. Baker DW, Brook RH, Stevens CD. Regular source of ambulatory care and medical care utilization by patients presenting to a public hospital emergency department. JAMA 1994;271:1909 –12. 20. Belville R, Godbold JH, Landrigan PJ, Pollack SH. Occupational injuries among working adolescents in New York State. JAMA 1993;269:2754 –59. 21. Ehlers JK, Ballard T, Connon C, Myers JR, Themann CL. Health and safety hazards associated with farming. AAOHN J 1993;41:414 –21. 22. Leigh JP, Miller TR. Ranking occupations based upon the costs of job-related injuries and diseases. J Occup Environ Med 1997;39:1170 – 82. 23. Sandefur GD. Racial and ethnic inequality in earnings and educational attainment. Soc Serv Rev 1989;63:199 –221. 24. Rivkin SG. Black/white differences in schooling and employment. J Human Resources 1995;30:826 – 852. 25. Heiss J. Effects of African American family structure on school attitudes and performance. Soc Probl 1996;43:246 – 67. 26. Adams JP, Dressler WW. Perceptions of injustice in a black community: dimensions and variation. Hum Rel 1988;41:753– 67. 27. Wortley S, Hagan J, Macmillan R. Just des(s)erts? The racial polarization of perceptions of criminal justice. Law Soc Rev 1997;31:637–76. 28. Henderson ML, Cao L, Cullen FT. The impact of race on perceptions of criminal injustice. J Crim Jus 1997;25:447– 62. 29. Burger J. Environmental attitudes and perceptions of future land use at the Savannah River Site: are there racial differences? Toxicol Environ Health 1998;53:255– 62. 30. Morgenstern, H. Uses of ecologic analysis in epidemiologic research. Am J Public Health 1982;72:1336 – 44. 31. Halpern R. Community-based early intervention. In: Head Start Bureau, Office of Human Development Services, U.S. Department of Health and Human Services. Handbook of early intervention, Administration for Children, Youth, and Families. Washington, DC: Government Printing Office, 1990. 32. Currie J, Thomas D. Does Head Start make a difference? Am Econ Rev 1995;85:341– 64. 33. Seltzer R. Race, age, education and knowledge of AIDS. Sociol Soc Res 1989;73:189 –93. 34. Din-Dzietham R, Hertz-Picciotto I. Infant mortality differences between whites and African-Americans: the effect of maternal education. Am J Pub Health 1998;88:651– 6. 35. Piroth S. Social issues and voting behavior. Soc Educ 1996;60:368 –73. 36. Schneider PA. Social barriers to voting. Update on Law-Related Education 1996;20:21–33. 37. Hamilton J. Politics and social costs: estimating the impact of collective action on hazardous waste facilities. Rand J of Econ 1993;24:101–25. 38. Hamilton J. Testing for environmental racism: prejudice, profits, political power? J Policy Anal Manage 1995;95:107–32.
Am J Prev Med 2000;19(3)
179
Heads of 763 low-income households participating in Head Start programs in 20 counties of the Mississippi Delta region were surveyed regarding their education, the physical environment of their home and workplace, sources of food and water, awareness of local polluting sites/facilities, knowledge of government agencies, and behaviors that may affect their health or impact their local environment. Survey results were compared to demographic, socioeconomic, and environmental quality indicators.
Results:
Significant associations existed between both education and race/ethnicity and the responses of survey participants. Being African American was more commonly associated with poor quality-of-life indicators such as renting substandard older homes and living in close proximity to areas of unfavorable watershed quality. Higher education was more commonly and positively associated with indicators of heightened environmental awareness and increased political empowerment. No association was observed between race/ ethnicity and the prevalence of polluting facilities. However, a significant association existed between race/ethnicity and indicators of environmental quality/integrity.
Conclusions: Environmental health education interventions that target individual households may be a useful mechanism for increasing the access of low-income communities to government health resources and reducing adverse health effects from the environment. However, racial/ethnic disparities in education and health remain an important consideration. Medical Subject Headings (MeSH): environmental health, health education, poverty, social justice (Am J Prev Med 2000;19(3):174 –179) © 2000 American Journal of Preventive Medicine
D
uring the past century, significant advances have been made toward improving the health, longevity, and quality of life of individuals in the United States.1 However, there are still numerous populations within the United States whose health and quality of life lag behind that of the general population and, in some cases, are comparable to developing countries.2,3 These populations are often comprised of low-income and/or minority racial/ethnic groups, creFrom the Carolina Environmental Program, University of North Carolina-Chapel Hill (Preston), Chapel Hill, North Carolina; Office of Urban Affairs, Agency for Toxic Substances and Disease Registry, U.S. Department of Health and Human Services (Warren), Atlanta, Georgia; and Natural Science and Environment Education Programs, Inc. (Stewart), Edwards, Mississippi Address correspondence and reprint requests to: Rueben C. Warren, DDS, MPH, DrPH, U.S. Department of Health and Human Services, Office of Urban Affairs, Agency for Toxic Substances and Disease Registry, 1600 Clifton Road NE, Mailstop E-28, Atlanta, GA 30333. E-mail: [email protected].
174
ating a socioeconomic and racial/ethnic disparity in health.4 –7 Although this disparity is attributed in part to differences in infant mortality, heart disease, cancer, cirrhosis, diabetes, and injury among racial/ethnic and socioeconomic groups, public health professionals have yet to account for a significant portion of the health disparity.4,8 Increasing evidence suggests that disproportionate risk of exposure to environmental hazards among low-income and minority groups may contribute to the disparity in health. One review of 30 studies of environmental risks identified racial/ethnic or socioeconomic disparities in ⬎80% of cases.9 For example, landfills and other hazardous waste storage facilities have historically been constructed in communities that are predominantly low-income and minority.10 Similarly, facilities that release contaminants included in the U.S. Environmental Protection Agency’s (EPA) Toxic Release Inventory (TRI) are concentrated in low-income, minority communities as well.11–13
Am J Prev Med 2000;19(3) 0749-3797/00/$–see front matter © 2000 American Journal of Preventive Medicine • Published by Elsevier Science Inc. PII S0749-3797(00)00195-1
In 1994, President Clinton issued Executive Order 12898, requiring federal agencies to consider environmental justice issues in their activities to help ensure that low-income and minority communities are not disproportionately exposed to environmental risks. Executive Order 12898 was intended to address a broad range of issues related to the environment, including economics, environmental regulation and planning, health effects, and environmental education. However, many environmental justice debates continue to center on past, present, and future siting of polluting and/or potentially hazardous facilities. Although these are important public policy considerations, environmental threats may result from the circumstances at the level of the individual household. For example, lead paint, pesticides, and contaminated drinking water are frequent environmental concerns, although the immediately affected population may consist of a limited number of individuals. Therefore, a hierarchical approach to environmental justice policy is necessary to implement interventions at the national, state, regional, community, and household levels. The state of Mississippi has historically been an area challenged by widespread economic depression, poverty, poor health status, and undereducation.14 These problems are further exacerbated by real or perceived environmental contamination and degradation that occur disproportionately in minority communities.15 As a result, a large portion of the state has been included in the Mississippi Delta Project (MDP), an initiative to address the environmental issues of the Mississippi Delta region and their relationship to human health and quality of life.14 The current study was designed to assess the influences of community urbanization, income, racial/ethnic composition, and education on environmental awareness and exposure to potential environmental hazards among Head Start families in Mississippi. A total of 763 low-income, female heads-ofhousehold were surveyed for their knowledge on environmental issues and daily behaviors that may affect the health of their families. In addition, a qualitative assessment of the environmental quality within the communities of survey respondents was performed. Subsequently, data on population size, racial/ethnic composition, and socioeconomic indicators were collected to test for associations between these factors and the responses of survey participants and the environmental quality of their communities.
Materials and Methods Data regarding environmental awareness and behaviors were collected through the administration of a 77-item survey, developed by Mississippi Action for Progress Inc. (MAP), and sent to female-headed households with children (aged 2 to 5) participating in the Head Start programs in the 20 counties of the MAP service area (Alcorn, Calhoun, Chickasaw, Claiborne, Franklin, Hancock, Itawamba, Lauderdale, Leflore,
Lincoln, Neshoba, Pearl River, Perry, Prentiss, Scott, Tippah, Tishomingo, Union, Warren, and Yalobusha). A total of 804 Head Start households was selected at random out of the approximately 5000 households participating in MAP Head Start programs. The head of each participating household was asked to complete a written survey containing questions regarding her age, race, and education, the physical environment of the home and workplace, sources of food and drinking water, awareness of local waste sites or polluting facilities, and familiarity with government agencies addressing environment and health issues. All participants were asked to read and sign consent forms containing a description of the survey and the environment health project. Survey administrators attended a two-day course on understanding and administering the survey prior to its use and were available to answer questions about the survey while it was being completed. A total of 763 (95%) participants completed the survey, representing 2974 children and adults. The average time for completion of the survey was 90 minutes. Chi-square analysis (␣⫽0.05) was used to assess whether the responses of survey participants to a subset of survey questions varied significantly with race/ethnicity (Caucasian, African American, or other) or education (high school grad/GED or less, or education beyond high school) under the null hypothesis of no significant difference in responses among racial/ethnic and educational categories. Numerous environmental quality indicators were obtained for the 20 counties in the MAP service area. All data on environmental quality were obtained through various databases maintained at the U.S. Environmental Protection Agency’s (EPA) Internet website (http://www.epa.gov). The number of polluting facilities and hazardous waste sites regulated by the EPA for each county at the time the study began was obtained from the EPA’s Envirofacts databases. These sites included facilities receiving permits under the National Pollution Discharge Elimination System (NPDES), facilities listed under the Aeromatic Information Retrieval System (AIRS), facilities listed under the Toxic Release Inventory, facilities regulated by the Resource Conservation and Recovery Act (RCRA), and National Priority List (NPL) sites regulated by the Comprehensive Environmental Response Compensation Liability and Recovery Act (CERCLA). The 1998 Pollution Standards Index (PSI) for air quality was obtained for each county from EPA’s Center for Environmental Information and Statistics (CEIS). Possible PSI values were good, moderate, unhealthful, very unhealthful, or hazardous, indicating relative risk of adverse effects to humans. Counties were checked for compliance with the Clean Air Act (CAA) through EPA’s Environmental Indicators database. All public drinking water providers in each county in 1998 and their 10-year violation history were identified through the EPA’s Safe Drinking Water Information System (SDWIS). Major watersheds within each county were identified through EPA’s CEIS. The index of watershed indicators (IWI) score (1996), the percentage of surveyed watershed miles supporting statedesignated usage (1996), the number of fish advisories issued (1997), and the principal contaminants were obtained for each watershed in each county (1996). IWI scores ranged from 1 to 6, with 1 indicating high quality and 6 indicating low quality. Results for all watersheds within a county were averaged to obtain an overall indicator of county watershed health.
Am J Prev Med 2000;19(3)
175
Table 1. Frequency of responses (%) to survey inquiries, stratified by race/ethnicitya Inquiry
Total (%) (Nⴝ763)b
Caucasians (%) (nⴝ169)b
African Americans (%) (nⴝ561)b
Other (%) (nⴝ19)b
Education beyond high school Own vs rent home Reside in a city/town Obtain food from a personal farm Eat game caught by household member Reported landfill in county Reported chemical plant in county Dispose of automobile antifreeze improperly Smoker in household Problems with insects in home Problems with rodents in home
51 53 48 10 73 35 21 75 30 37 15
54 66 32 20 82 44 15 76 41 22 9
48 48 53 8 64 33 23 54 26 36 17
79 50 53 5 53 22 28 91 53 13 13
p ⬍.05 ⬍.001 ⬍.0001 ⬍.001 ⬍.01 ⬍.05 ⬍.05 ⬍.0001 ⬍.001 ⬍.01 ⬍.05
a
Only statistically significant results are shown. Number of individuals in each category completing the survey. However, survey respondents did not necessarily respond to all inquiries.
b
Demographic data—including population size, race/ethnicity, education, per capita income, and per capita sales— were collected for each of the 20 counties in the MAP service area. Data were obtained from the U.S. Census Bureau through the Government Information Sharing Project at Oregon State University. The most recent year for which data were available for population size and racial/ethnic composition was 1997. The most recent data year available for education, income, and sales was 1995. Associations among county demographic characteristics, responses of survey participants, and county environmental quality indicators were assessed by calculating correlation coefficients (␣⫽0.05, df⫽18).
Results Responses to MAP Survey Most survey respondents (75%) were African American, while 23% were Caucasian, and the remaining 2% were of other races/ethnicities. One percent of respondents were aged 15 to 18; 52%, 19 to 29; 30%, 30 to 39; and 17%, ⱖ40. Household size ranged from 1 to 13, with a mean and median size of 4. When asked about the highest level of education completed, 4% of respondents completed elementary school, 51% completed high school or received a GED, 5% attended a vocational school, 29% attended some college, 7% graduated from college, and 4% pursued graduate studies. For the purpose of statistical analyses, respondent education was pooled into two categories of similar sample size: (1) high school education or less, and (2) education beyond high school. Significant associations existed between both the education and race/ethnicity of respondents and the frequency of responses to a number of survey inquiries (Tables 1, 2, 3).
Environmental Indicators A total of 1719 EPA-regulated, polluting facilities/sites was identified in the 20 counties of the MAP service area. The number of facilities per county ranged from 27 to 242 with a mean of 86. No NPL sites were 176
identified in any of the 20 counties. All 20 counties were in compliance with the Clean Air Act, and the PSI for air quality was “moderate” for all 20 counties, indicating few or no health effects related to air pollution for the general population. A total of 228 public drinking water providers was identified, ranging from 7 to 30 per county, with a mean of 11. These drinking water providers reported a total of 686 violations between 1988 and 1998, ranging from 2 to 86 per county with a mean of 34. These violations resulted from exceeding permissible contaminant levels in drinking water or problems in monitoring contaminant levels or facility maintenance. The vast majority of these violations were related to coliform contamination, although a few were related to violation of lead/copper criteria. A total of 41 watersheds were identified, with a mean of 4 per county; however, a single watershed could traverse multiple counties. The median IWI score for watersheds in the 20 counties was 3 (“less serious, low vulnerability”), indicating moderate problems with con-
Table 2. Frequency of responses (%) to survey inquiries, stratified by educationa Inquiry Own vs rent home Know causes of food poisoning Reported chemical plant in county Reported incinerator in county Know agency to contact re: surface water problems Know agency to contact re: drinking water problems Know whether or not drinking water is monitored a
p
53 74
48 70
58 78
⬍.01 ⬍.05
21
18
25
⬍.05
16
18
15
⬍.05
30
21
38
⬍.01
58
49
62
⬍.0001
35
30
39
⬍.05
Only statistically significant results are shown. Number of individuals in each category completing the survey. However, survey respondents did not necessarily respond to all inquiries. b
American Journal of Preventive Medicine, Volume 19, Number 3
Table 3. Percentage of survey respondents reporting familiarity with specific environmental and health agencies, stratified by race/ethnicity or education
Agency U.S. Environmental Protection Agency U.S. Department of Health and Human Services Centers for Disease Control and Prevention U.S. Department of the Interior U.S. Department of Agriculture Mississippi State Department of Health Mississippi Department of Environmental Quality Mississippi Wildlife, Fisheries, and Parks Department Mississippi Regional Poison Control Facility County Health Department
African Total (%) Caucasians (%) American (%) Other (%) (nⴝ561) (nⴝ19)a p (Nⴝ763)a (nⴝ169)a
>High
22
28
21
21
NS
16
27
⬍.001
37
36
32
32
NS
33
41
⬍.05
25
30
26
26
NS
18
32
⬍.0001
6 23 38
8 22 37
11 32 42
11 32 42
NS NS NS
5 17 32
8 29 44
NS ⬍.0001 ⬍.001
11
11
16
16
NS
8
14
⬍.01
26
23
48
48
NS
22
30
⬍.05
20
27
32
32
NS
16
24
⬍.01
40
38
53
53
⬍.05 35
46
⬍.01
p
a
Number of individuals from each category completing the survey. However, survey respondents did not necessarily respond to all inquiries. NS, not significant
tamination and/or human impacts. However, nine counties had mean IWI scores of 4 or 5, indicating more serious contamination/impacts. The mean percentage of surveyed miles of surface water meeting designated usage ranged from 10% to 71% for the 20 counties, with an overall mean of 43%. A total of 24 fish advisories were issued or in effect in 1997 across the 20 counties. The most common pollutants in rivers and streams were pesticides, nutrients, siltation, organic enrichment, and pathogens (bacterial/viral).
County Demographics and Socioeconomic Indicators Data from the U.S. Census Bureau indicated that the mean 1997 population size for the 20 counties in the MAP service area was 27,559 — of which 69% were Caucasian; 29%, African American; 1%, Native American; 0.2%, Asian/Pacific Islanders; and 0.8%, Hispanic. On average, 48% of the county populations were male. In 1995, approximately 59% of adults aged ⱖ25 had graduated from high school and 11% had graduated from college. Mean 1995 per capita income and per capita retail sales were $13,832 and $5041, respectively. Large variations existed between counties with respect to size, racial/ethnic composition, education, and income. In addition, significant correlations were found among demographic/socioeconomic indicators, the responses of survey participants, and indicators of environmental quality (Table 4).
Discussion In addition to the traditional concerns of race/ethnicity in environmental justice, the results of this study
suggest that differences in education among groups may be an additional concern in addressing environmental health issues. Survey respondents who had education beyond high school were consistently more likely to be familiar with government agencies with responsibilities in the area of health and the environment (Table 3). Respondents tended to be more familiar with health agencies (e.g., the U.S. Department of Health and Human Services, the Mississippi State Health Department, and county health departments) than they were with agencies specializing in environmental issues. This disparity may result from the dependence of this population on public health agencies/ facilities, particularly local health departments, for basic health care needs.16 –19 In addition, although 35% of respondents reported a landfill within their county, 1995 data from EPA’s Office of Solid Waste indicates that only three regulated municipal landfills exist within the MAP service area (in Lauderdale, Pearl River, and Scott counties). This may reflect a false perception of environmental hazards among this population and/or a general lack of familiarity with local polluting facilities. Although the education of survey participants did not seem to influence their sources of food or water, participants from counties with higher proportions of high school and college graduates were more likely to be connected to public water providers and less likely to obtain their food from a personal farm or utilize wild game as a food source. Utilizing personal farms, hunting, and fishing for food sources may be associated with increased risk of food-borne exposure to contaminants. For example, 12 of the 20 counties in the MAP service Am J Prev Med 2000;19(3)
177
Table 4. Results of correlation analyses testing associations between county demographic characteristics, environmental quality indicators, and responses to survey inquiries for 20 counties in the MAP service areaa Independent variable
Dependent variable
R
County population size
Per capita income Per capita sales Percentage of high school graduates Percentage of college graduates Percentage of respondents residing in city/town
0.63 0.77 0.54 0.68 0.46
⬍0.01 ⬍0.01 ⬍0.05 ⬍0.01 ⬍0.05
County per capita income
Per capita sales Number of EPA sites in county Percentage of respondents who consume game caught by household member
0.73 0.7 ⫺0.55
⬍0.01 ⬍0.01 ⬍0.05
Percentage of high school graduates
Percentage of college graduates Number of EPA sites in county Percentage of households using well water as source of drinking water Percentage of households obtaining food from personal farm Percentage of households with farm worker Percentage of households with factory worker
0.55 0.58 0.49
⬍0.05 ⬍0.01 ⬍0.05
⫺0.49 ⫺0.62 ⫺0.62
⬍0.05 ⬍0.01 ⬍0.01
0.46 0.58 0.56 0.52 0.46 0.58
⬍0.05 ⬍0.01 ⬍0.01 ⬍0.05 ⬍0.05 ⬍0.01
⫺0.51
⬍0.05
0.66 ⫺0.59 0.5 ⫺0.47 0.49
⬍0.01 ⬍0.01 ⬍0.05 ⬍0.05 ⬍0.05
Percentage of college graduates
Percentage of minorities in population
Per capita sales Percentage of minorities in population Number of EPA sites in county Percentage of households in a city/town Percentage of households with home ⬎25 years old Percentage of households using well water as source of drinking water Percentage of households that consume game caught by household member Index of watershed indicators score Percentage of surface waters meeting designated usage Home ⬎25 years old Know causes of food poisoning Problems with insects in home
p
a Only statistically significant results are shown. MAP, Mississippi Action for Progress, Inc.; EPA, U.S. Environmental Protection Agency
area had at least one fish advisory in 1997. Thus, communities with higher levels of education may be more likely to select low-risk sources of food such as commercial distributors. The predominant factors determining the education level of counties appeared to be population size, which was also associated with income. Thus, individuals from more populated areas are predicted to be better educated and wealthier on average, which is likely a function of diversity in and access to educational and employment opportunities. This is supported by the observation that respondents from counties with higher proportions of high school graduates also reported fewer household members working in factory/manufacturing or agricultural jobs (Table 4), which are often associated with more health impacts than other areas of employment.20 –22 Although education may be an important factor affecting environmental risk, race/ethnicity did influence environmental quality and respondent awareness. The percentage of survey respondents who had education beyond high school was significantly higher among Caucasians than African Americans (Table 1), reflecting the national racial/ethnic 178
disparity in education and socioeconomic status.23–25 Minority survey respondents were less likely to own their own homes, reside in rural areas, or smoke, and African Americans were more likely to report problems with both insect and rodent infestations than Caucasians. Similarly, respondents from counties with higher proportions of minorities in the population were more likely to report residing in a house constructed ⬎25 years ago or report problems with both insect and rodent infestations (Table 4). In addition, there was a highly significant correlation between the minority composition of counties and indicators of watershed quality. Lastly, the fact that minorities were more likely to report the presence of both landfills and chemical plants within their communities (Table 1) suggests that minorities may have greater environmental concerns and/or perceptions of injustice than Caucasian communities.26 –29 It should be noted that this study has several limitations. First, we cannot exclude the possibility of recall bias or error in the self-reported responses of survey participants. Second, environmental indicators, such as the number of polluting facilities or watershed quality
American Journal of Preventive Medicine, Volume 19, Number 3
are not indicators of exposure; as a result, they are not necessarily associated with risk. Third, analysis at the county level may not be sensitive enough to detect more localized interactions between demographics and environmental quality. Fourth, although correlation analyses (Table 4) indicated that significant associations existed among numerous variables, no definitive conclusions regarding the cause for these associations can be made.30 Lastly, given the absence of controls, the fact that surveyed households were participating in a program targeting families with specific characteristics and the over-representation of African Americans in the survey population, it seems unlikely that the survey population was representative of the general population of Mississippi or the United States. Education stands out as an important factor governing individual behaviors, economic opportunity, and access to resources for this population. Education has also been demonstrated to have significant impact on personal health and quality of life.31–34 Promoting health education through such programs as Head Start may help mitigate the adverse effects of socioeconomic and environmental challenges to health. However, race/ethnicity remains an important consideration and continued efforts should be directed at reducing racial disparities in health, education, and involvement in environmental decision making. In addition, improving the access of low-income/minority communities to environmental health education and resources may increase their political involvement, thereby bringing attention to existing environmental problems and preventing future racial/ethnic or socioeconomic disparities in environmental management.35–38 The benefits of urban life—access to education, health care, reliable sources of food and water, and nonindustrial or nonagricultural jobs—suggest that the promotion of economic development and urbanization may improve the health and quality of life for individuals in the predominantly rural state of Mississippi. The authors would like to acknowledge the assistance of the Regional Research Center for Minority Health, Morehouse School of Medicine, and Mississippi Action for Progress, Inc., in conducting this study.
References 1. Erhardt CL, Berlin JE. Mortality and morbidity in the United States. Cambridge, MA: Harvard University Press, 1974. 2. McCord C, Freeman HP. Excess mortality in Harlem. N Engl J Med 1990 322:173–7. 3. Fullilove RE, Aidala AA, Bassett MT, et al. Risk factors for excess mortality in Harlem: findings from the Harlem Household Survey. Am J Prev Med 1999;16(suppl 3):22– 8. 4. U.S. Department of Health and Human Services. Report of the Secretary’s Task Force on Black & Minority Health. Washington: Government Printing Office, 1985. 5. Freeman HP. Poverty, race, racism, and survival. Ann Epidemiol 1993;3: 145–9. 6. Mason JM. Understanding the disparities in morbidity and mortality among racial and ethnic groups in the United States. Ann Epidemiol 1993;3:120 – 4.
7. Warren RC. The morbidity/mortality gap: what is the problem? Ann Epidemiol 1993;3:127–9. 8. Otten M, Marks J, Siber R, Teutsch S, Williamson D. The effect of known risk factors on the excess mortality of black adults in the United States. JAMA 1990;263:845–50. 9. Allen D, Lester J, Hill K. Prejudice, profits, and power: assessing the eco-racism thesis at the county level. Paper presented at the Western Political Science Association Annual Meeting, Portland, OR, March 16 –18, 1995. 10. Bullard R. Dumping in Dixie: race, class, and environmental quality. Boulder, CO: Westview, 1990. 11. Burke L. Race and environmental equity: a geographic analysis in Los Angeles. Geo Information Info Sys 1994;October:44 –50. 12. Cutter S. The burdens of toxic risks: are they fair? Business Econ Rev 1994;40:101–13. 13. Pollock P, Vittas ME. Who bears the burdens of environmental pollution? Race, ethnicity, and environmental equity in Florida. Soc Sci Q 1995;76: 294 –310. 14. Nathan VR, Gatebuke J, Knuckles M. Mississippi Delta Project: health and environment. Nashville, TN: Division of Environmental Health, Meharry Medical College, 1995. 15. Mielke HW. The urban environment and children’s health: soils as an integrator of lead, zinc, and cadmium in New Orleans, Louisiana, USA. Environ Res 1999;81:117–29. 16. Kleinman JC, Gold M, Makuc D. Use of ambulatory medical care by the poor: another look at equity. Med Care 1981;19:1011–29. 17. Miller CA, Brainard MP, Brown ML, Kotch JB, Moos MK. Role of local health departments in the delivery of ambulatory care. Am J Public Health 1981;71:15–29. 18. Newacheck PW, Butler LH. Patterns of physician use among low-income, chronically ill persons. Med Care 1983;21:981–9. 19. Baker DW, Brook RH, Stevens CD. Regular source of ambulatory care and medical care utilization by patients presenting to a public hospital emergency department. JAMA 1994;271:1909 –12. 20. Belville R, Godbold JH, Landrigan PJ, Pollack SH. Occupational injuries among working adolescents in New York State. JAMA 1993;269:2754 –59. 21. Ehlers JK, Ballard T, Connon C, Myers JR, Themann CL. Health and safety hazards associated with farming. AAOHN J 1993;41:414 –21. 22. Leigh JP, Miller TR. Ranking occupations based upon the costs of job-related injuries and diseases. J Occup Environ Med 1997;39:1170 – 82. 23. Sandefur GD. Racial and ethnic inequality in earnings and educational attainment. Soc Serv Rev 1989;63:199 –221. 24. Rivkin SG. Black/white differences in schooling and employment. J Human Resources 1995;30:826 – 852. 25. Heiss J. Effects of African American family structure on school attitudes and performance. Soc Probl 1996;43:246 – 67. 26. Adams JP, Dressler WW. Perceptions of injustice in a black community: dimensions and variation. Hum Rel 1988;41:753– 67. 27. Wortley S, Hagan J, Macmillan R. Just des(s)erts? The racial polarization of perceptions of criminal justice. Law Soc Rev 1997;31:637–76. 28. Henderson ML, Cao L, Cullen FT. The impact of race on perceptions of criminal injustice. J Crim Jus 1997;25:447– 62. 29. Burger J. Environmental attitudes and perceptions of future land use at the Savannah River Site: are there racial differences? Toxicol Environ Health 1998;53:255– 62. 30. Morgenstern, H. Uses of ecologic analysis in epidemiologic research. Am J Public Health 1982;72:1336 – 44. 31. Halpern R. Community-based early intervention. In: Head Start Bureau, Office of Human Development Services, U.S. Department of Health and Human Services. Handbook of early intervention, Administration for Children, Youth, and Families. Washington, DC: Government Printing Office, 1990. 32. Currie J, Thomas D. Does Head Start make a difference? Am Econ Rev 1995;85:341– 64. 33. Seltzer R. Race, age, education and knowledge of AIDS. Sociol Soc Res 1989;73:189 –93. 34. Din-Dzietham R, Hertz-Picciotto I. Infant mortality differences between whites and African-Americans: the effect of maternal education. Am J Pub Health 1998;88:651– 6. 35. Piroth S. Social issues and voting behavior. Soc Educ 1996;60:368 –73. 36. Schneider PA. Social barriers to voting. Update on Law-Related Education 1996;20:21–33. 37. Hamilton J. Politics and social costs: estimating the impact of collective action on hazardous waste facilities. Rand J of Econ 1993;24:101–25. 38. Hamilton J. Testing for environmental racism: prejudice, profits, political power? J Policy Anal Manage 1995;95:107–32.
Am J Prev Med 2000;19(3)
179