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. Author manuscript; available in PMC: 2025 Feb 9.
Published in final edited form as: Libr Inf Sci Res. 2024 Feb 9;46(1):101283. doi: 10.1016/j.lisr.2024.101283

Public library lending programs increase radon testing in rural communities

Stacy R Stanifer a, Kathy Rademacher a, Whitney Beckett a, King Simpson b, Mary Kay Rayens a,c, Amanda Thaxton-Wiggins a, Ellen J Hahn a,c
PMCID: PMC10919551  NIHMSID: NIHMS1963710  PMID: 38463029

Abstract

Radon exposure is the second leading cause of lung cancer, yet few Americans test their homes for radon, particularly in rural areas. The academic team and community partners engaged the public library systems in four rural counties to offer digital radon detectors for check-out as a means of increasing the public’s access to free radon testing. The check-out procedures and instructional materials were created through an iterative process, and library personnel were educated on radon and home radon testing prior to launching the lending program. Library patrons reported high usability, feasibility, and acceptability of the program. Library patron-staff interactions mainly included discussions about the logistics of radon testing. Given that public libraries are invested in making communities thrive and promoting health, providing library lending programs for radon detectors is a novel, feasible, and acceptable way to reduce the risk of lung cancer in the community.

1. Introduction

Public libraries have long been recognized as essential, trusted sources of information, resources, and community service. With few barriers to access, libraries serve as community hubs and those in the health sector are beginning to recognize public libraries as key community partners in addressing public health concerns (Philbin et al., 2019). In the United States, lung cancer is a significant public health concern, as the disease is the leading cause of cancer mortality yet highly preventable (American Cancer Society, 2024). Exposure to radon is a contributing factor to the disease, yet much of the public is unaware of the danger (Vogeltanz-Holm & Schwartz, 2018). Partnerships between those in public health and public libraries that serve to increase radon awareness and increase home radon testing may be one way to address lung cancer in the United States.

1.1. Radon and lung cancer

Radon is a colorless, odorless, radioactive gas that develops from the natural decay of uranium found in bedrock and soil (World Health Organization, 2023). The World Health Organization and the Environmental Protection Agency (EPA) recognize radon as a human carcinogen (Environmental Protection Agency [EPA], 2023a). As the gas is inhaled, the radioactive particles are deposited along the respiratory tract, delivering tiny doses of radiation to the cells lining the airway and causing DNA damage. In the U.S., radon is the second leading cause of lung cancer. Annually, approximately 21,000 lung cancer deaths are attributed to radon exposure (EPA, 2023b). Although radon exposure is an independent risk factor for lung cancer, evidence suggests radon and tobacco work synergistically to increase one’s risk of developing lung cancer nearly 10-fold, meaning people who are exposed to both radon and tobacco are at greater risk of lung cancer than people exposed to radon alone (National Research Council Committee on Health Risks of Exposure to Radon, 1999). Additionally, risk of lung cancer increases with exposure to higher concentrations and longer durations of radon exposure (National Research Council Committee on Health Risks of Exposure to Radon, 1999).

1.1.1. Radon testing and action level

Across the U.S., the risk potential for elevated indoor radon is known to vary (EPA, 1993); however, there is no safe level of radon exposure. Most exposure to radon occurs in the home when the gas enters and accumulates where Americans spend a large part of their day. The EPA recommends all homes regardless of geographic location be tested for radon and has set an action level of 4.0 picocuries per liter of air (pCi/L) or 148 becquerels per cubic meter (Bq/m3) (EPA, 2016). Both pCi/L and Bq/m3 are acceptable units of measures for the radioactivity of radon within a volume of space. In addition to the EPA, the U.S. Surgeon General has issued a nationwide health advisory encouraging home radon testing (United States Department for Health and Human Services, 2005). Despite these major recommendations, few American homes have been tested (Eheman et al., 1996; Wang et al., 2000). In Kentucky, the EPA has designated 112 of the 120 counties (93%) as having moderate-to-high radon risk potential (EPA, 1993), yet annually only 13 of every 10,000 homes test for radon (Stanifer et al., 2022a). Lower income (Halpern & Warner, 1994; Hill et al., 2006; Nissen et al., 2012; Zahnd et al., 2018); lower education (Butler et al., 2018; Halpern & Warner, 1994; Nissen et al., 2012; Zahnd et al., 2018); lower median home value (Stanifer et al., 2022a); lack of home ownership (Hill et al., 2006; Wang et al., 2000); high county-level adult smoking prevalence (Stanifer et al., 2022a); and rurality (Zahnd et al., 2018) are all factors associated with lack of home radon testing.

2. Problem statement

Although exposure to radon is the second leading cause of lung cancer, most Americans have not tested their homes for radon, and the lack of home testing is more acute in rural communities (Zahnd et al., 2018; Stanifer et al., 2020). Testing for radon in the home can be done using do-it-yourself detectors purchased over the counter or on-line. When radon levels measure at or above 4.0 pCi/L (148 Bq/m3), the EPA recommends homeowners take action to reduce indoor levels by hiring a certified radon measurement professional (EPA, 2016). To increase radon awareness and home radon testing, public libraries can be valuable, yet underutilized, partners by offering patrons free access to radon testing equipment. Public libraries are a trusted source of information, have few barriers to access, and are increasingly being utilized to improve population health. Thus, the purpose of this pilot study was to create and evaluate a novel radon detector kit library lending program (radon LLP) for usability, feasibility, acceptability, and likelihood to mitigate radon in each of four rural public libraries. This study aims to provide support for the inclusion of radon LLPs at public libraries across the United States as a means of preventing lung cancer by increasing radon awareness and home radon testing in the U.S.

3. Literature review

3.1. Public libraries and public health

As Philbin et al., (2019) discussed, libraries across the country are providing direct healthcare services, health information, and linkage to healthcare services, addressing topics such as addiction, food, stress, and social support. For example, the Indiana University School of Social Work piloted a social work student practicum placement at the public library in Indianapolis to address the unmet psychosocial needs of patrons (Wahler et al., 2021). Students provided services for patrons’ unmet needs, including financial, food and nutrition, housing, transportation, and hygiene (Wahler et al., 2021). Another project implemented a Lunch at the Library summer meal program to address food insecurity among school aged children in 22 library jurisdictions in California. Stakeholders reported the lunch program addressed food insecurity of children, promoted utilization of the library and learning, and brought new patrons to the library (De La Cruz et al., 2019).

3.1.1. Public libraries and radon

Although libraries are equipped to lend more than books, a radon LLP is a novel approach to increasing access to radon detectors in the United States. In Canada, the Lung Association of Nova Scotia and Prince Edward Island collaborated with public libraries in Nova Scotia and Prince Edward Island to make over 300 radon detectors available for check-out by library patrons (Lung Association of Nova Scotia and Prince Edward Island, 2022). The lending program was so popular that there are now over 388 library branches across Canada that lend radon detector kits to patrons (Government of Canada, 2021). Drawing upon the innovation and success of the radon LLPs in Canada, the University of North Dakota and University of Georgia have recently partnered with local and state public libraries, respectively, to make radon detector kits available to library patrons (Miller, 2023; Phillips, 2023). In both states, officials reported the need for greater radon awareness and testing and have made the free kits available to anyone with a library card.

4. Methodology

4.1. Research approach

The pilot study reported here is part of a larger National Institute of Environmental Health Sciences funded community-engaged research study, Radon on the RADAR (Residents Acting to Detect and Alleviate Radon). The study aims to increase the public’s access to equipment used for home radon testing and affordable radon mitigation in rural communities by employing a citizen science approach and geohealth methodology. Citizen science is a research approach that engages volunteer members of the public to work in tandem with researchers to participate in the scientific process. In preparation for the radon LLP pilot, 15 citizen scientists were recruited in each of four rural Kentucky counties and educated on how to test their home for radon using continuous, digital radon detectors called Corentium Home by Airthings® and advise the academic research team on use of the detector, data interpretation, and community-based planning (e.g., marketing of the radon LLP, coalition building) (Stanifer et al., 2022b; Hahn et al., 2023). The four rural counties were selected by the research team because of their radon risk potential (Figure 1) and then matched on county-level median income and population size (Table 1). To determine the rate of radon testing per county, 81,941 observed radon values were retrieved from two companies that received and analyzed short-term test kits from Kentucky property owners between 1986 and 2019. Using this dataset, the number of tests in each of the counties were ascertained and divided by the corresponding number of households in that county. All four study counties have relatively low rates of home radon testing, ranging from <1.0% of homes tested for radon in County A to 9.8% in County D (Fig. 1).

Fig. 1.

Fig. 1.

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Radon potential and percent of homes tested by study county

Table 1.

Demographic characteristics of RADAR study counties.

County Populationa Median incomeb Smoking ratec RUCCd Number of housing unitse* % homes tested for radon Radon Potential
A 73,995 $38,904 25.3 2 29,723 < 1.0 High
B 26,835 $36,590 23.0 6 12,312 3.1 High
C 23,333 $35,236 20.2 7 10,128 1.8 Low
D 63,063 $34,092 22.5 5 31,189 9.8 Low
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*

Includes houses, apartments, mobile homes, single room/group of rooms intended as separate living quarters

Each study county has its own library system, operated by a board, management, and staff members. Given that all study counties are rural, the service populations are small to medium in size. The number of locations per county is variable: Counties A and C each have one main location; County B has three locations and County D has five (one main location and four branches). In addition, Counties C and D have bookmobiles. Those with branch locations and bookmobiles are equipped and accustomed to sharing books and other items among the multiple sites within their system, as well as offering online resources to their respective communities. Most of the library systems had previous experience lending nontraditional items, such as bicycles, musical instruments, laptops, and wi-fi hotspots, before participating in the radon detector lending program.

The pilot study design reported here was observational and prospective. The radon LLP was designed using an iterative process to revise the materials and check-out procedures based on library partners and citizen scientists’ input. Next, the library staff were provided informational training on radon, radon testing, and how to use the radon detector kits. Each library was given 25 radon detector kits to catalog in their libraries. Library directors then determined how the kits would be distributed within their libraries. Those with only one branch kept all 25 at their main location while others made some kits available at satellite branches or on bookmobiles. The radon LLP was available year-round and free of charge to all library patrons 18 years of age and older who were in good standing with the library and held a valid library card, regardless of whether they agreed to participate in the research study.

The pilot study ran for 15–17 months, depending on the library, and engaged in paid and unpaid marketing and promotions inside each of the four public library systems and in their respective communities. For the pilot, citizen scientists (n = 15 per county) were asked to utilize their social networks to educate others in their community about radon, share information about the radon LLP, and encourage at least one community member per month to check out a radon detector from the library. The citizen scientists were not asked to follow up to assess whether the community members checked out a radon detector from the library due to confidentiality considerations. A tip sheet for citizen scientists was developed, which suggested what to share when talking about radon (e.g., testing for radon is easy), ways to share radon LLP information (e.g., social media, faith community bulletin), and the benefits of the radon LLP (e.g., keeping your home and family safe). Among those who agreed to join the pilot study, usability, feasibility, and acceptability were measured via three separate online surveys from the perceptions and self-report of the radon LLP participants, citizen scientists, and library staff. Library patrons who joined the research study were entered into a quarterly drawing for a $50 gift card.

4.2. Study population

Anyone 18 years of age or older who was in good standing with the library and held a valid library card could check out a radon detector. To be eligible for study participation, the library patron must have been 18 years of age or older, speak and read English, own their home, or live in the home and be responsible for decisions about home repair. During the pilot phase of the radon LLP (October 2021-February 2023), a total of 319 residents checked out the radon detectors and 86 participated in the research study (27% participation rate). Eleven of the 86 participants were unable to enter their radon data online (13%; 8 did not have internet and 3 did not have an email address).

4.3. Designing the radon LLP

The research team engaged the directors of each public library and site partners (e.g., citizen scientists, site PIs, and site coordinators) at the start of the planning process to share the purposes and goals of the radon LLP. Hearing from site partners and the library directors allowed the research team to understand community and library system differences. Input from each library and site partner was used to guide the design of the program and to promote program sustainability. Using an iterative process and guided by library directors and site partners, the radon detector kit contents, informational materials (e.g., instruction cards, training video for patrons, Radon Action Plan), the procedures for lending (e.g., user agreement) returning the radon detector kits, and training for library staff were developed. In addition, the program was designed to maintain study participant confidentiality, meaning the library staff would not know if a library patron joined the study or not after borrowing a kit from the library.

4.3.1. Radon detector kit contents

Sturdy, cloth, zippered carrying cases were purchased to safely store the following contents of the radon detector kit: an Airthings Corentium Home Radon Detector, 3 AAA batteries (stored in a zippered section of the carrying case), laminated instruction cards (see below), and a radon data collection card for those without internet access (Fig. 2). The Corentium Home radon detector is an easy to use, portable, battery-operated digital device that provides continuous real-time radon gas monitoring in picocuries per liter (pCi/L). The device has an easy-to-read display showing both short-term (1-day) and long-term (2 weeks or longer) readings (Airthings®, 2023). Study participants were asked to upload their daily and 2-week average radon data via Qualtrics (Qualtrics, Provo, UT). For those without internet access, participants were asked to fill out the radon data collection card included in the detector kit. The card included space for the participant to write their 1-day radon number from day 1 to day 14, and their 2-week long-term average number on day 15.

Fig. 2.

Fig. 2.

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Image of radon detector kit.

4.3.2. Informational materials

Three types of radon LLP informational materials for library patrons were developed: instruction cards, video, and Radon Action Plan. First, instruction cards were designed and field-tested to explain how to place and use the Airthings detector. The contents of the kit were summarized and a link to a short video demonstrating use of the detector was provided (see below). The instruction cards included information on where to test in the home (e.g., lowest livable level of the home where someone in the household spends at least 8 hours per week); where not to place the detector (e.g., bathrooms with high humidity); how to start testing, considerations during the testing period (e.g., do not move the detector; keep windows and exterior doors closed except for normal use); troubleshooting; what the radon numbers mean; and frequently asked questions. The frequently asked questions, for example, provided information on the accuracy of the detectors and reasons for fluctuations in radon numbers (e.g., weather conditions, seasonal considerations, and open windows and exterior doors during the testing period).

Second, a brief 3-minute video, How to Test Your Home for Radon (link to YouTube included on instruction cards; not shared publicly), was developed demonstrating the best place to test your home, and use of the Corentium Home detector, including how to insert the batteries, how to interpret the display including both short-term (1 day) and long-term (14 days) average numbers, and how to contact study staff for additional assistance.

Lastly, a printed Radon Action Plan was developed and summarized what the radon numbers mean, described the synergistic risk that occurs when dually exposed to radon and tobacco smoke (Butler et al., 2018), and what patrons should do if their numbers are high (≥ 4.0 pCi/L), mid-range (2.0–3.9 pCi/L), or low (< 2.0 pCi/L). The process of reducing high radon, called radon mitigation, was defined, and included estimated cost, ranging from $800-$2500. The Radon Action Plan included information about the state law and that they may be eligible for a mitigation voucher for 30% off the cost of mitigation (up to $600) if they take part in the research study and use a study-approved radon mitigation professional. In addition, the Radon Action Plan provided links to radon educational resources such as the EPA’s A Citizen’s Guide to Radon (EPA, 2016).

4.3.3. Lending and return procedures

Kits were available year-round, and patrons could borrow a radon detector kit for 3 weeks at a time, allowing for two weeks of testing and time to return the kit to the library. Instruction cards included information on the radon study and how to join the study either by phone or online. Those who enrolled in the study were asked to test continuously for a total of 2 weeks and document their short-term 1-day average radon number every 24-hours either online (e.g., smartphone, computer) or using the radon data collection card included in the kit; the instructions were to record the radon number at approximately the same time each day. After the two-week testing period ended, study participants were asked to report their 2-week long-term average radon number. The research assistant monitored progress at two time points: five days after each enrollment and at the end of the testing period. If fewer than three values were entered for the first five days of testing, the research assistant generated an automated email to the participant as a prompt to remind them to enter their daily radon number. Participants who did not complete the program electronically were mailed an enrollment packet and the research assistant called them five days after mailing to confirm receipt and remind them to mail the completed radon data card and survey after completing testing.

Based on suggestions from library directors and to promote accountability, a 2-page radon detector user agreement was developed for the library staff to review with the patron during check out. The first page is for library use only and includes the patron’s name and contact information; the initials of the staff member(s) who checked out and checked in the kit; radon detector kit number; how the patron heard about the radon LLP; and a place to initial the patron’s responsibility for seven elements of checking out, caring for, and returning the kit. The second page of the user agreement is for the library patron, and includes the check out period, rules of check out (e.g., loaned only to the library card holder) and kit return (e.g., remove batteries and secure in the case; use of book drop for returns not allowed); and information about participating in the research study.

Upon return, library staff wiped the radon detector kits with a dry cloth and ensured batteries had been removed from the detector and placed in a zippered section of the carrying case. Library staff also replaced missing or damaged kit materials (e.g., instruction cards, batteries, data collection cards) and removed any items that did not belong in the kit.

4.3.4. Training library staff

Library staff attended a virtual 30-minute staff training session in real-time prior to launching the radon LLP. Recordings and copies of the training slides were provided for staff who were unable to attend. The training included the goals of the study; why their county was selected; information about the Corentium Home radon detector; the basics of radon and what radon numbers mean; radon mitigation basics; and the radon LLP lending and return procedures. A Frequently Asked Question sheet specific for library staff was also created, which included radon and health effects information; home radon testing details; testing using the Corentium Home by Airthings® radon detector; and details about participating in the research study (e.g., eligibility, what the participant will be asked to do, and how to assist participants without internet access).

4.4. Study procedures

Once the library staff placed and catalogued the radon detector kits, the 60 citizen scientists were asked to recruit a total of 400 homeowners (100 per county) to check out the devices, test their homes for 2 weeks, document their radon numbers, and return the kits to the library. Each citizen scientist was expected to recruit, via fliers and word of mouth, at least one resident per month for 10 months to check out a radon detector from the library. Citizen scientists were asked to complete radon LLP-related survey questions as part of the larger study survey. At the completion of the 2-week testing period, library study participants were asked to complete a brief online or paper post testing survey to assess their experiences. Participants without internet access were mailed a postage-paid return envelope, the paper post testing survey, and the Radon Action Plan. Participants were instructed to use the postage-paid return envelope to mail their completed post-testing survey and data collection card to the research team. Experiential feedback gathered from the participant surveys enabled the community-academic team to revise the radon LLP to make it more user-friendly and effective.

4.5. Measures

4.5.1. Library loan participant surveys

Once enrolled in the study, participants completed a sociodemographic and housing characteristics survey, including age, sex, race, ethnicity, educational attainment, income, tobacco use among anyone living in the home, children in the home, personal history of radon testing, housing type, foundation type, and years living in the home. After testing and returning the detector kit to the library, participants were asked to complete a second survey which assessed usability, feasibility, acceptability, and likelihood to mitigate for radon. Usability was defined as how the LLP participants used the radon device and the component parts of the kit. For usability, participants were first asked whether they reviewed the kit materials (i.e., instruction sheet, training video, Radon Action Plan, educational resources), and a summative score (potential range 0–4) was created to represent the number of materials they reviewed. They were also asked if the device worked as expected, with response options ranging from 1= Strongly disagree to 5= Strongly agree. Feasibility was defined as how doable or easy it was to test for radon using the kit. For feasibility, participants were asked to rate the degree to which each of the four materials were easy to understand (1= Strongly disagree to 5= Strongly agree) and an average score was calculated. Cronbach’s alpha for the four ease of understanding items was 0.87. They were also asked if they entered their radon numbers online and, if so, what device they used, and to rate the degree to which entering radon numbers each day was easy (1= Strongly disagree to 4= Strongly agree). Acceptability was defined as how well the LLP served its purpose. For acceptability, participants were asked to rate the degree to which each of the four materials were helpful (1= Strongly disagree to 5= Strongly agree), and an average score from these items was calculated. Cronbach’s alpha for these four acceptability items was 0.83. They were also asked about the likelihood of recommending the LLP to others and reasons they would not recommend the program. Lastly, two items measured the likelihood of radon mitigation including the possibility of hiring a certified radon mitigation professional and whether financial help would assist them in mitigating radon.

4.5.2. Citizen scientist survey

In the larger study, 60 citizen scientists were invited to complete surveys multiple times. At baseline, citizen scientists completed a survey assessing self-efficacy for testing and mitigating high radon, health information literacy, environmental health literacy, and response efficacy (Stanifer et al., 2022b). The survey is administered after each home radon testing timepoint and other study activities (e.g., radon LLP promotion) to evaluate the same endpoints over time beginning at three months post testing. For evaluating the pilot radon LLP reported here, citizen scientists were asked to complete a survey 6–9 months after the start of the radon LLP. The 10-item survey assessed how citizen scientists promoted the radon LLP (e.g., email, social media, posting flyers), the perceived effectiveness of each promotion method, the impact of the COVID-19 pandemic on their ability to promote the radon LLP, and what they had heard in the community about the radon LLP.

4.5.3. Monthly detector kit circulation report and patron interactions

Each month, an online survey was sent to a library staff member asking them to report monthly circulation data on the number of detectors checked out, and the number of detectors lost or damaged. Library staff were also asked to report the types of relevant questions or interactions with library patrons including those about radon, radon testing, the detector kit, and the research study.

4.6. Data analysis

Descriptive statistics, including frequency distributions or medians and interquartile ranges (IQRs), were used to summarize sociodemographic and housing characteristics among the radon LLP participants. Characteristics between those who completed the posttesting survey and those who did not were compared using chi-square tests of association, Fisher’s exact tests, or Mann-Whitney U tests, as appropriate. Usability, feasibility, acceptability, and likelihood to mitigate were summarized descriptively among the radon LLP participants after testing, and the two scales with four items each (for assessing feasibility and acceptability) were evaluated for internal consistency using Cronbach’s alpha. Associations among sociodemographic, housing and radon value with likelihood to recommend the radon LLP were also assessed using chi-square tests of association, Fisher’s exact tests, or Mann-Whitney U tests, as appropriate. All data analysis was conducted using SAS, version 9.4, with a significance level of .05 used for inferential testing.

5. Findings

5.1. Radon LLP participants

A total of 86 participants enrolled in the radon LLP pilot study and completed the demographic and housing survey. Of these, 68 also completed the posttesting survey (79%). The median age of participants was 61 years (IQR = 46 – 68), and the majority were female (69%; see Table 2). Nearly all participants (98%) were White, non-Hispanic, two thirds had at least a college education (66%), and nearly one third reported a household income of $90,000 or higher (30%). Fewer than 10% lived in a home with a tobacco user and the majority did not have any children living in the home (71%). Most participants lived in a single-family home (97%) and the most frequent foundation type was crawl space (50%), followed by walkout (29%), and basement (25%). The median number of years living in the home was 12 years (IQR = 2 – 25) Most participants had never tested their home for radon prior to the study (81%). More than one third of participants reported a 2-week long-term average radon number ≥ 4.0 pCi/L (40%).

Table 2.

Descriptive summary of library loan participant sociodemographic and housing characteristics by those who completed the post-testing survey and those who did not.

Total sample median (IQR) or n (%) Completers (n = 68) median (IQR) or n (%) Non-completers (n = 17) median (IQR) or n (%) p
Age 61 (46 – 68) 63 (48 – 71) 50 (37 – 65) .025a
Sex .65b
 Male 25 (29.4%) 19 (27.9%) 6 (35.3%)
 Female 59 (69.4%) 48 (70.6%) 11 (64.7%)
 Other 1 (1.2%) 1 (1.5%) 0 (0.0%)
Race/ethnicity .038b
 White, non-Hispanic 83 (97.65%) 68 (100.0%) 15 (88.2%)
 Black, non-Hispanic 2 (2.35%) 0 (0.0%) 2 (11.8%)
Education .96a
 High school or below 7 (8.2%) 6 (8.8%) 1 (5.9%)
 Some college 22 (25.9%) 16 (23.5%) 6 (35.3%)
 College graduate 26 (30.6%) 23 (33.8%) 3 (17.6%)
 Post-graduate 30 (35.3%) 23 (33.8%) 7 (41.2%)
Household income .055a
 <$29,999 18 (22.0%) 17 (26.1%) 1 (5.9%)
 $30,000 - $59,999 19 (23.2%) 15 (23.1%) 4 (23.5%)
 $60,000 - $89,999 20 (24.4%) 16 (24.6%) 4 (23.5%)
 $90,000 - $119,999 12 (14.6%) 8 (12.3%) 4 (23.5%)
 $120,000 or higher 13 (15.8%) 9 (13.9%) 4 (23.5%)
Tobacco use in home .20b
 Yes 8 (9.3%) 8 (11.8%) 0 (0.0%)
 No 78 (90.7%) 60 (88.2%) 18 (100.00%)
Children living in the home .075b
 Yes 24 (28.6%) 16 (23.9%) 8 (47.1%)
 No 60 (71.4%) 51 (76.1%) 9 (52.9%)
Housing type .11b
 Single family home 83 (96.5%) 67 (98.5%) 16 (88.9%)
 Mobile home 3 (3.5%) 1 (1.5%) 2 (11.1%)
Years living in current home 12 (2 – 25) 17 (3 – 25) 7 (1 – 20) .18a
Ever tested your home for radon .81c
 Yes 16 (18.6%) 13 (19.1%) 3 (16.7%)
 No 70 (81.4%) 55 (80.9%) 15 (83.3%)
Long-term radon test results .23b
≥4pCi/L 30 (40.0%) 29 (42.7%) 1 (14.3%)
 Yes 45 (60.0%) 39 (57.3%) 6 (85.7%)
 No
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Note: N = 86. Numbers vary due to missing data on individual items; completers (n=68) and noncompleters (n = 18).

Abbreviation: IQR = interquartile range

a

P-value from Mann-Whitney U test.

b

P-value from Fisher’s exact test.

c

P-value from Chi-square test of association.

In comparing those who completed the post testing survey (n = 68) and those who did not (n = 18), completers were significantly older (median = 63, IQR = 48 – 71 vs. median = 50, IQR = 37 – 65; p = .025), and a higher proportion of completers were White, non-Hispanic (100% vs. 88%, p = .038; see Table 2). There were no differences between completers and noncompleters on sex, education, income, tobacco use among anyone living in home, children in the home, housing type, years living in the home, radon testing history, or radon testing results.

Among the 68 participants who completed the post testing survey, ratings on Usability of the device were high. On average, participants reviewed 3.3 (SD =0.8) of the four materials related to radon and/or testing, and there was high agreement that the device worked as expected (M = 4.7 out of a maximum score of 5, SD = 0.5; see Table 3). For Feasibility, based on a potential range of 1–5, participants agreed that the materials were easy to understand (M = 4.6, SD = 0.5). The majority entered their radon numbers online (89%), and most reported using a smartphone (56%), followed by personal computer (33%). The average rating for ease of entering data online was 3.9 (SD = 0.5, with a potential range of 1–4). For Acceptability, the average rating for helpfulness of the materials was high (M = 4.6, SD = 0.5; potential range 1–5), as was likelihood to recommend the radon LLP (M = 3.9, SD = 0.5; potential range 1–4). Age, sex, race, ethnicity, education, tobacco use among anyone living in the home, and long-term radon testing number (above or below the EPA action level) were not associated with likelihood to recommend the radon LLP. Radon LLP participants provided positive comments, reflecting the acceptability of the program, stating, “…I would have never thought to test my home if this service had not been provided,” “I appreciate this program was available to me without cost,” and “I appreciate this excellent resource from my local library…” There were no differences in usability, feasibility, or acceptability outcomes based on whether the participant had previously tested for radon.

Table 3.

Summary of library loan participants’ views of usability, feasibility, acceptability, and likelihood to mitigate.

Potential range Mean (SD); range or n (%)
Usability
Number of materials reviewed (instructions, training video, Radon Action Plan, educational resources) 0–4 3.33 (0.75); 1–4
Device worked as expected 1–5 4.65 (0.51); 3–5
Feasibility
Ease of understanding materials 1–5 4.59 (0.52); 3–5
Entering radon data each day was easy 1–4 3.89 (0.31); 3–4
Acceptability
Helpfulness of materials 1–5 4.56 (0.48); 3–5
Likely to recommend the Library Loan Program (n = 47 a) 1–4 3.87 (0.49); 1–4
Likelihood to mitigate
Likely to hire mitigation professional (n = 36 b) 1–4 3.34 (0.94); 1–4
Financial help assist in mitigation system installation (n = 36 b) 1–4 3.63 (0.78); 1–4
Open in a new tab

Note: (n = 68);

a

Based on n = 47 (question added after start of study);

b

Based on n = 36 (only those who reported at least one daily or a long-term radon number ≥ 4.0pCi/L (148 Bq/m3)

Slightly less than half the participants who completed the post testing survey said they had a long-term 2-week radon number ≥ 4.0 pCi/L (n = 29; 42.7%). Among the 36 participants who reported having a radon number of 4.0 pCi/L or higher on any of the days they tested, the average likelihood of hiring a mitigation professional was 3.3 (SD = 0.9; maximum rating of 4), and they largely agreed that having financial help would assist them in having a mitigation system installed (M = 3.6 on a 4-point scale, SD = 0.8).

5.2. Citizen scientists

Among the 60 citizen scientists, 58 completed the survey evaluating how they shared the pilot radon LLP in their community. Nearly all reported sharing information about the program (95%). The most frequent methods of sharing information were word of mouth (86%), social media (47%), email (21%), giving someone a copy of the study flier (21%) and text (19%). On a scale of 1–5, the methods ranked most effective were word of mouth (M = 4.1, SD = 1.0) and social media (M = 4.0, SD = 0.9). Slightly more than one quarter said the COVID-19 pandemic at least somewhat impacted their ability to share information about the radon LLP (29%). When asked what they had heard about the radon LLP in their community, approximately one quarter of citizen scientists said they heard others planned to borrow a radon detector kit from the library soon (29%) and heard people telling others about the program (24%). Relatively few reported hearing from others that they had tested their home for radon (3%) or borrowed a kit from the library (9%).

5.3. Library staff

Library staff reported a total of 319 devices checked out from the four study libraries. Three detectors were lost and two were returned to the library damaged (5% rate of lost or damaged detectors). There were 151 interactions with patrons about the radon LLP. Most interactions with patrons were specifically related to the radon device (38%), followed by home radon testing in general (23%), radon (20%), and the research study (16%). For questions specific to the radon device, the most frequently asked questions were whether the detector was accurate (14%) and where to place the detector (13%). Of interactions related to home radon testing, the most frequently asked questions were how to measure radon (12%), what testing location to use (9%), and how long to test (8%). For questions specific to radon, why test for radon (9%) and what to do if radon is high (7%) were the most common. The most frequent question asked about the research study was whether they were eligible to check out a detector (12%).

Finally, library staff indicated what actions they took when asked questions about the radon LLP. From most to least frequently endorsed, they distributed copies of the flier (44%), referred the patron to the research team (13%), provided the website link or copy of the Radon Action Plan (6%), provided a website link to the flier (5%), and referred the patron to the library (3%).

6. Discussion

The study is the first to examine the usability, feasibility, and acceptability of a radon LLP. In addition, how likely participants were to mitigate radon when actionable levels were detected in the home was examined. Overall, the radon LLP was successful in promoting home radon testing in the four rural counties as patrons borrowed a total of 319 radon detector kits over the 15–17 months. Similar to other studies of home radon testing in rural communities, the sample of 86 who participated in the radon LLP pilot study was older (Stanifer et al., 2020) and of higher income (Hill et al., 2006). The risk of developing lung cancer is associated with concentration and duration of radon exposure (National Research Council Committee on Health Risks of Exposure to Radon, 1999). Anyone, regardless of age and socioeconomic status, may be at risk of exposure to radon in their home. Therefore, all homeowners need to test for radon to know their number. It is promising that most radon LLP participants (81.4%) had never tested their home for radon prior to borrowing a kit, providing support for establishing radon LLPs in rural public libraries to increase access to home radon testing.

Of those who completed the post testing survey, patrons found the radon LLP to be usable, feasible, and acceptable. Of the four resources accompanying the radon detector kits, all patrons reported using the instruction cards, and nearly all used the Radon Action Plan. Nearly three quarters reviewed the EPA’s Citizen’s Guide to Radon, and two thirds watched the How to Test Your Home for Radon training video. Most participants reported these four resources were helpful and easy to understand. Furthermore, the majority reported the Airthings Corentium Home Radon Detector worked as expected, demonstrating ease of use. Overall, most participants reported they would likely recommend the radon LLP to others in the community.

Over 40% who completed the post testing survey reported having an actionable 2-week long-term average radon number. Given that most of these participants had lived in their home for more than 16 years and had never tested for radon underscores the importance of radon LLPs and having radon testing accessible and affordable to everyone. After learning they were living with high radon, these participants seemed motivated to act to reduce radon, as many reported they would likely hire a certified radon mitigation professional. As with many across the U.S., cost is often cited as a barrier to radon mitigation (Denu et al., 2019; Khan & Chreim, 2019; Riesenfeld et al., 2007; Wang, 1999). Our participants reported that having financial help to offset the cost of radon mitigation would likely assist them in having a radon mitigation system installed. Currently, in the U.S., very few financial resources are available to assist low-income homeowners with radon mitigation, further perpetuating disparities in health (Amos et al., 2021). Policies supporting the use of federal and state funds for mitigation assistance are critically needed.

Paid and unpaid marketing and promotions were used to draw patrons to the radon LLP (e.g., billboard, radio, bookmarks, library signage) in each of the four public library systems and in the respective communities. Citizen scientists also recruited residents to check out a radon detector from the library, primarily via word of mouth and social media, and they reported these as the most effective methods of spreading the word. Nearly one in three citizen scientists reported hearing others who planned to borrow a radon detector kit; one quarter reported people talking about the radon LLP. Despite efforts to increase awareness and create social norms around radon testing, the research team fell short of their goal of 400 homeowners borrowing a radon detector kit. Further, only 9% of citizen scientists reported hearing of others who had borrowed a kit from the library to test their home. It is important to note that although the citizen scientists were asked to encourage community members to check out a radon detector from the library, they were not expected to follow up to assess what, if any, action they took to test their homes. These findings contrast with the radon LLP experience in Canada. There, the popularity of the radon LLP expanded the program to 388 public libraries across the country (Government of Canada, 2021). Further research is needed to understand low radon testing rates in rural communities, despite outreach efforts. Regardless, those who participated were appreciative of the radon LLP.

The benefits of the radon LLP may extend beyond that of the individual patron. By increasing access to affordable home radon testing through radon LLPs, libraries introduce another avenue for outreach to those who might otherwise not have visited the library. Further, programs such as these demonstrate that public libraries are interested in health promotion and invested in making communities thrive. Findings point to the importance of educating library personnel about radon and having educational resources available at the library prior to implementing a radon LLP. Across the U.S., rates of home radon testing remain low (Eheman et al., 1996; Stanifer et al., 2022a; Wang et al., 2000), so it was expected that patrons would ask library personnel questions about radon, radon testing, and the radon detector. Given the library staff training, library personnel were equipped to answer patrons’ radon and health-related questions as well as direct them to resources such as the instruction cards, Radon Action Plan, training video, and EPA’s Citizen’s Guide to Radon.

6.1. Limitations

This study had several limitations. First, anyone with a public library card in good standing could check out a radon detector and learn about the research study. Convenience sampling may have resulted in self-selection bias and may have contributed to the relatively high ratings of usability, feasibility, and acceptability of the LLP. Further, those who completed the pilot study were significantly older and of White, non-Hispanic descent. Because the sample was older (M =58.1) and largely white, non-Hispanic (97.65%), findings may not be generalizable to homeowners who are younger and of black, non-Hispanic descent. In general, the convenience sample may not be representative of those who frequent the library as, according to at least one library director, they tend to see a higher proportion of people of color, of lower income, and of lower educational attainment. It is important to note that although renters could check-out a radon detector (Hahn et al., 2017), they were not eligible for the research study. In addition, it is possible that the citizen scientists communicated about the radon LLP with people in a similar demographic as themselves. Most citizen scientists were of higher income and education, and most were White (Stanifer et al., 2022b). These limitations impact the generalizability of our findings.

Second, the research team attempted to gather monthly detector kit circulation data and patron interactions from each of the four libraries, however, data gathering was inconsistent as three of the four libraries had director and staff turnover during the pilot study. Although the research team tracked detector kit checkouts weekly by assessing available inventory on the library websites, this was not the best way to determine participation rates. Although the weekly online inventory data reflected cross-sectional detector kit availability at each library, there was overlap between kits that were borrowed, returned, and renewed.

7. Conclusion

Despite the limitations, this study is the first to examine the usability, feasibility, acceptability of a radon LLP in public libraries and provides support for the inclusion of radon LLPs at public libraries across the United States to foster lung cancer prevention efforts. Furthermore, the findings advance understanding of the impact of public health and public library partnerships to address environmental health concerns and promote population health. This public health and library partnership approach shows promise in increasing access to home radon testing. Future programs would benefit from additional research to understand low radon testing rates in rural communities and to promote radon risk reduction through public policy change, particularly policies which reduce disparities and make radon mitigation accessible and affordable to everyone.

Highlights.

  • The radon detector library loan program was designed and evaluated using citizen science methods.

  • The radon detector library loan program was usable, feasible and acceptable to library patrons.

  • Library patrons were appreciative of having access to radon detector kits at no cost.

  • Public libraries can serve as partners to promote the health of communities.

  • Radon detector loan programs are innovative and attract community members who may not have otherwise utilized the library.

Acknowledgements:

We thank our library partners, community advisory board, and citizen scientists for their valuable contributions to the project.

Funding:

This project is supported by the National Institute of Environmental Health Sciences (NIEHS) through Grant R01 ES030380 and supported in part by Grant P30 ES026529. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIEHS.

Author Biography

Stacy Stanifer is a clinician scientist and assistant professor in the College of Nursing at the University of Kentucky. She holds her PhD in nursing from the University of Kentucky. Her research focuses on furthering the science related to reducing co-exposure to two environmental carcinogens, radon and secondhand smoke, as a means of lung cancer prevention and has been published in Western Journal of Nursing Research, The Journal of Rural Health, Citizen Science: Theory and Practice, and Policy, Politics, and Nursing Practice.

Kathy Rademacher is the director of data management and sharing for BREATHE (Bridging Research Efforts and Advocacy Toward Healthy Environments) at the University of Kentucky College of Nursing. She received her Bachelor of Arts in psychology from the University of Kentucky. Kathy is a certified expert user of REDCap and Qualtrics, and she has more than 16 years of research survey development and data management. Her research experience is primarily focused on tobacco control, vulnerable populations, and radon.

King Simpson is the director of the Logan County Public Library in rural Southcentral Kentucky. He holds an MS in library & information science from the University of Kentucky. King serves as the site principal investigator for the “Radon on the RADAR” project and is involved in numerous local and statewide efforts to improve the impact of libraries on their respective communities, which is his passion.

Whitney Beckett is a data management analyst in the College of Nursing BREATHE (Bridging Research Efforts and Advocacy Toward Healthy Environments) department at the University of Kentucky. She holds her Bachelor of Public Health from the University of Kentucky and is currently in the second year of her Master of Public Health program at the University of Kentucky with a concentration in health systems and policy analytics. Her work at BREATHE is focused in data management among projects related to radon and tobacco.

Mary Kay Rayens is a professor at the University of Kentucky Colleges of Nursing and Public Health. She completed her PhD in statistics at the University of Kentucky and her expertise is in biostatistics, particularly as it relates to clean indoor air policy. She is Co-Director of the University of Kentucky BREATHE (Bridging Research Efforts and Advocacy Toward Healthy Environments) and her research in this area relates to both radon and tobacco. Her research has been published in Tobacco Control, Nicotine & Tobacco Research, Environmental Health Research, and International Journal of Environmental Research and Public Health.

Amanda Thaxton Wiggins is a senior lecturer in the College of Nursing at the University of Kentucky. She holds her PhD in biostatistics and epidemiology from the University of Kentucky and serves as a faculty associate of the University of Kentucky BREATHE (Bridging Research Efforts and Advocacy Toward Healthy Environments) and her research in this area relates to both radon and tobacco. Her research has been published in American Journal of Obstetrics & Gynecology, Nurse Education Today, and Public Health Nursing.

Ellen J. Hahn is a professor in the Colleges of Nursing and Public Health at the University of Kentucky (UK). She holds her PhD in health policy/health of the community at Indiana University School of Nursing. Dr. Hahn is Director for UK-CARES (Center for Appalachian Research in Environmental Sciences) and Director for the Occupational and Environmental Health Nursing Core of the NIOSH-funded Central Appalachian Regional Education and Research Center. Dr. Hahn also directs BREATHE (Bridging Research Efforts and Advocacy Toward Healthy Environments). Her research interests are in population-based environmental risk reduction interventions using citizen science approaches; and development and testing of evidence-based policy advocacy interventions. Her research has been published in American Journal of Public Health, Journal of Rural Health, American Journal of Health Promotion, International Journal of Environmental Research and Public Health, Nicotine and Tobacco Research, Health Promotion Practice, among others.

Footnotes

Declaration of interest: none.

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