The Role of Environmental Health Literacy When Developing Traffic Pollution Fact Sheets for Puerto Rican Adults

Fact sheet development

We developed three fact sheets to communicate health risks associated with air pollution from traffic. The first fact sheet summarized previous research conducted by the CAFEH study on the health effects of long-term exposure to UFPs from motor vehicle traffic. ¹⁸ The second fact sheet described the CAFEH project and its collaboration with the BPRHS. The third fact sheet was designed to communicate how researchers were evaluating the relationship of traffic-related UFP levels with risk of developing cardiovascular disease (see Supplementary Data for fact sheets).

Each fact sheet presented foundational knowledge deemed critical to understanding environmental exposure and the health risks associated with traffic-related air pollution. Critical knowledge was what UFPs are, how they might affect health, and the basic nature of our research. These fact sheets were originally written in English and then translated into Spanish. We assessed the reading grade level in English using the Flesch-Kincaid readability assessment tool in Microsoft Word. Flesch-Kincaid grade level scores ranged from 10.8 to 12.9. The Flesch-Kincaid readability formula is not validated for use with Spanish text, so we did not assess readability of the Spanish fact sheet before using them in focus groups. Later in the project, we added an assessment using the Fry readability graph, which is validated for use in both English and Spanish. ¹⁹ This yielded results within two grade levels of the original assessment. There was virtually no change in reading grade level after revisions.

Focus group recruitment

The study protocol was approved by the Tufts IRB and all participants gave signed and informed consent. We recruited a convenience sample from the BPRHS cohort. We obtained a list of potential recruits from the cohort who had previously demonstrated a willingness to participate in research requests. We contacted prospective participants by phone and offered $50 in cash and a light meal as compensation for their time and participation.

Focus group methodology

The focus groups were held at a community center in a Boston neighborhood that had a substantial Puerto Rican population. Each focus group lasted approximately one and a half hours and took place in the early evening to accommodate those who worked during the day. The first two focus groups (N = 16) were held in the summer of 2014. The second set of focus groups (N = 13) were held in the spring of 2015 and included the same participants, minus three who were lost to follow-up.

We conducted the sessions in Spanish, but due to the bilingual nature of many participants, some conversation (10%–20%) took place in English. A member of the research team who was fluent in both Spanish and English facilitated all focus groups. A transcriber who was also a bilingual member of the research team audio recorded sessions and took notes.

Each fact sheet was discussed separately and participants were asked the same set of questions regarding each one (Table 1). The facilitator used these questions to guide the conversation, but left room for natural discussion. Participants were instructed to read each fact sheet individually at their own pace. The facilitator guide for the second set of focus groups was edited to reflect that revisions had been made to the fact sheets (Table 1).

Bilingual members of the researcher team transcribed focus group audio recordings verbatim in Spanish and, as needed, in English. After reviewing the transcripts, we estimated that about 5% was inaudible or indecipherable. Once a final transcription had been produced, the Spanish portion was translated into English by one bilingual member of the research team. Another bilingual team member verified the accuracy of the translations.

Revision of the fact sheets

A revised set of fact sheets was developed based on feedback from focus group discussions with BPRHS participants. Themes elicited from the first set of focus groups were used to guide the revision process. Bilingual members of the researcher team who attended the focus groups transcribed and translated the audio recordings, conducted the content analysis, consulted with each other, and agreed upon revisions for the fact sheets.

Revisions included changes to both the text and layout. We increased the size of the text, added more pictures and graphics, increased the amount of white space to each page, organized the information into chunks with subheaders, added more content, and used more local vocabulary and plain language. (Supplementary Data—revised fact sheets+translation).

Data analysis

We used an inductive approach to identify themes and then highlighted and categorized participant comments. A grounded theory framework allowed themes to emerge from the data. Two members of the research team reviewed each set of focus group transcripts separately, coding participant comments by theme. They then discussed discrepancies in their coding and agreed upon a final list of six themes (Table 2). Transcripts were hand coded using a different color marker for each theme.

Focus groups: first round

Table 2 shows the demographics of focus group participants. They were older adults, predominantly female, and earned a low income with only a high school education or less. A frequent theme (Table 3) from the first round of focus groups was that the content of the fact sheets was complicated and overwhelming. However, participants also said they wanted more information, particularly information about what the Puerto Rican community could do to lessen the dangers of exposure to UFPs. Other common themes were the severity of the problem and participants asking why the fact sheets focused only on Puerto Ricans.

Some participants expressed being overwhelmed by the information in the fact sheets. One participant stated, “I was really lost … I think it was just too much for me.” Another said, “I don't want to say that I didn't understand anything, but for me to read it I would need more time.” Other comments reflected understanding and satisfaction with how the information was explained. One participant said, “Speaking of the graphic, I like what they did and what is here is explained very, very well.”

There were frequent comments expressing confusion and difficulty understanding the fact sheets. One participant said, “What do you mean to say with 2.5?” referring to fine particulate matter or PM_2.5. Another participant said, “I didn't like [the fact sheet] because in a sense I read it, but I did not understand it well.” Yet another participant said she understood the fact sheet, adding, “The text needs to be more simple and the words could be more clear.”

Other comments expressed a desire for more information. One participant said, “I think…of course, I know that this is a study…but, a little more in-depth information, you understand?” When asked about the information in the fact sheets on illnesses that may be caused or exacerbated by exposure to UFPs, one participant said, “We want something more complete,” and “I do not think this is complete. I think that it needs more information.” A participant, after reading about UFPs, asked, “Are these particles visible, or do you need a microscope to see them?”

Another theme was the severity and potential dangers of air pollution within participants' neighborhoods. One participant said, “I knew that carbon dioxide was affecting me, in fact, when I lived on a major avenue.” Others said, “More traffic is bad for us,” and “I don't like the traffic because of this [content described in the fact sheets]. Because the smoke is harmful to you.”

Another topic was why the study focused on Puerto Ricans. For example, one participant remarked, “This is good but, I don't understand this—here where it says Puerto Ricans have worse health and less access to health care. But why? I don't understand this part.” Other comments revolved around the perspective of how they as people of a lower socioeconomic status were not able to escape these conditions. For example, one participant said, “It is that poor people live—not only Hispanics, but poor people. This is what affects us because we cannot buy a house where there is not traffic. Do you understand me? Like in the suburbs.”

Many comments in the first round of focus groups reflected a desire for more information on ways to mitigate the effects of air pollution. One participant said, “I like the way chemicals like these are explained, especially if they live in areas close to where there is a lot of traffic, like a highway. One breathes in all this smoke from cars and everything, and because of that people get sick from asthma and all the things that you know about. I am asking because it [the fact sheet] has details about this…what more are you going to do around here?” One participant said, “What is most important is the section that says, ‘What do we not know?’—that they have to research more things.” Another participant, after a discussion of the risks of living near highway pollution, said, “how do we avoid this thing?” A participant responded to her, “It [the fact sheet] can have more.”

Focus groups: second round

Fact sheets were revised based on themes identified in the first round of focus groups, specifically participants wanted the fact sheets to have both more relevant information and be easier to read (see Supplementary Data for revised fact sheets). Once the fact sheets were revised and reviewed by the research team, a second round of focus groups was used to assess their reception by members of the BPRHS cohort.

The revised fact sheets elicited comments that were more positive. When asked how these fact sheets compared with those that had been presented in the first round of focus groups, one participant said, “These are more clear…They have more information and more explanation.”

The increase in images, maps, and other visual aids in the fact sheets seemed to make a big difference in the participants' understanding. One said, “It is much easier to read with more illustrations. There are more photos, which helps.” When asked why they liked the photos better in the second round, one participant responded, “because they tell us how it is, where it is. They give you a clear image of what the sheet is saying.” Another participant said, “The graphic in this photo calls my attention because I recognize the name of the street. The photos are very good.”

There remained, however, some confusion over the size of UFPs based on the visual comparison to a strand of hair in the revised fact sheet. Some participants mistakenly thought that this meant that UFPs could lodge in one's hair.

Another change was the increase in comments related to understanding the severity and potential danger of air pollution. One participant commented that after reading the revised sheet, “we can understand these things more clearly: what can harm us, why we may have heart problems, where these problems come from. It has to do with the air, with cars, with gasoline which is very strong and not good for our lungs.” Another participant challenged the study by asking, “I would like to know how they can test or analyze if it is true that this [UFPs] is affecting someone. Are they doing this study on one person, medically, in order to know if they are being affected? That is what I want to know.” This participant also asked, “What is going to happen at the end of this study? They can't clean the air.”

Like the first round of focus groups, the second round elicited specific suggestions for improvement. Regarding vocabulary, one participant suggested that we only use the Spanish word for blood rather than the more technical phrase—bloodstream. She commented, “In the blood. You're using medical terms. Sangre to us. There you go.”

Strengths and limitations

The main strength of this study is that we engaged participants directly to identify what worked for them. Other strengths included that we addressed a highly specific topic with a narrowly defined population. This reduced uncertainty that would accompany a more general investigation. However, participants likely did not constitute a representative sample due to recruitment of a motivated subset of participants who were mostly women from the BPRHS. Future research on communicating complex environmental health information to Puerto Ricans should strive to reach a broader cross section.

Another potential limitation is that we used the same participants in both the first and second sets of focus groups. Some participants may have had a residual understanding of the topic that would make it easier for them to understand the revised fact sheets. Leaving three-quarters of a year between the first and second focus groups may have reduced this potential problem. On the other hand, we would have been open to an alternate critique if the second group of participants were new recruits. In that case, there would be a doubt as to whether the differences in response were due to changing the fact sheets or changing the participants.

Most participants were more fluent in Spanish than in English. Using both English and Spanish is a common practice in this population. Thus, another limitation is that some participants may have missed what was said in English, while others missed what was said in Spanish. However, this limitation is mitigated because this English/Spanish dynamic reflects how they speak in daily life.