Multidirectional Translation of Environmental Health Science in Community Settings: The Case of Oxidative Stress Pathways

Abstract

Background:

Translation of environmental health science in vulnerable communities is particularly important to promote public health and reduce health inequities.

Methods:

We describe a structured, multidirectional process used to develop a suite of health promotion tools (e.g., fact sheets, video, maps) documenting patterning of local air pollution sources and availability of antioxidant-rich foods in Detroit, Michigan as factors that jointly affect oxidative stress (OS). OS underlies many pathological processes associated with air pollution, including asthma, metabolic syndrome, cancer, diabetes, and obesity. This translational effort involved a 2-year dialogue among representatives from community-based and environmental organizations, health service providers, and academic researchers.

Results:

This dialogue led to development of tools, as well as new opportunities to inform related policies and research.

Conclusions:

Through this example, we highlight how collaborative partnerships can enhance multidirectional dialogue to inform translation of environmental health science by promoting consideration of multilevel risk factors, local priorities and context, and diverse audiences.

Neighborhoods with high rates of poverty and greater proportions of Black and Latino residents are more likely to have high levels of air pollution in the United States and to experience adverse health effects associated with these exposures.^1–3 Such communities may also have reduced access to resources to protect against adverse effects of air pollution, including information about pollution in their neighborhoods, health care to mitigate adverse effects of exposure, and policymakers who can influence policies that affect emissions.^4,5 Scientific evidence regarding the effects of environmental exposures on health and potential protective factors must be clearly translated to inform policy and program decisions that affect exposure to air pollution to promote population health and reduce health inequities.

Translational science often refers to the translation of research from ‘bench to bedside’ or ‘research to practice’ in clinical care settings, but community-based settings also offer key opportunities for translation.⁶ Traditional definitions of translational science often emphasize a unidirectional process⁷—from scientist to clinic or community. As the field progresses, however, there is increasing recognition of the importance of multidirectional pathways involving the reciprocal sharing of knowledge and experience among multiple partners.^8,9

In this paper, we describe a case example of multidirectional translation involving ongoing collaboration among representatives from community-based and environmental organizations, health service providers, and academic researchers. This process, which unfolded over a 2-year period, aimed to 1) translate the environmental health science of OS, one pathway through which air pollutants may affect health, to diverse audiences, 2) examine the patterning of air pollutants as a risk factor for OS in one local context—Detroit, Michigan, and 3) examine the distribution of antioxidant-rich foods as a potentially protective factor in that same local context. Through iterative dialogue and feedback, this group developed multiple complementary tools, including fact sheets, a video, and maps, to locally contextualize information about multiple dimensions of OS pathways that influence health. These tools work to make OS relevant for diverse audiences, including residents of Detroit and Southeast Michigan, educators, public health practitioners, and policymakers and decision makers. Simultaneously, tool development efforts spurred research to further address multidimensional community concerns. We close with a discussion of how tool development can foster multidirectional dialogue in community settings to enhance translational research efforts related to a variety of environmental health topics.

ESTABLISHING STRUCTURES AND PROCESSES TO SUPPORT MULTIDIRECTIONAL TRANSLATION

Structures and Processes for Collaborative Dialogue

The case example presented here was developed within the context of the Community Outreach and Engagement Core (COEC) of the University of Michigan Lifestage Environmental Exposures and Disease (M-LEEaD) Center and the corresponding Stakeholder Advisory Board (SAB; available from: http://ehscc.umich.edu/). COEC staff and SAB members are co-authors of this manuscript. M-LEEaD focuses on three pathways through which environmental exposures contribute to adverse health outcomes over the life course: OS, epigenetics, and endocrine disruptors. The COEC’s overarching goal, in partnership with the SAB, is to translate environmental health science to community and policy audiences, and to assure opportunities for those groups to inform scientific research on environmental health issues. The SAB includes representatives from several Detroit-based community organizations, along with local and state health service providers. The roles, goals, and relationships between the COEC staff, SAB members, and M-LEEaD scientists are depicted in Figure 1.

Figure 1.

University of Michigan Lifestage Environmental Exposures and Disease (MLEEaD) Partnership Structure.

Identification of Priority Issues

The SAB communicates community priorities to M-LEEaD scientists, guides dissemination of environmental health research findings, and fosters ongoing dialogue between the M-LEEaD Center, community members, policymakers, and other decision makers. Early in its existence, the SAB established operating norms to assure effective and equitable group processes¹⁰ regarding group decision making, identification of priority health issues, creation and dissemination of outreach materials (e.g., responsibility for development, review by SAB members and M-LEEaD scientists, editing), audience selection, review of language, and dissemination venues. Environmental health issues prioritized by the SAB include those associated with environmental exposures for which Detroit residents experience excess risk and prevalence. These include air pollution, which is associated with chronic conditions such as cardiovascular disease, metabolic disorders and asthma, for which Detroit residents experience excess risk.^11–14

Having established these priorities, SAB members work closely with M-LEEaD scientists and COEC staff to develop tools for translation of scientific research on these environmental health issues. Herein, we describe the process used to collaboratively develop multiple tools for diverse audiences to communicate about the SAB prioritized issue of air pollution. This process is illustrated in Figure 2, with web links to several of the resulting tools. At each stage, we describe the process itself, including crosscutting conversations that ensued and key contributions made by community and academic partners.

Figure 2.

Multidirectional translation of the environmental health science of oxidative stress: multiple tool development.

COLLABORATIVE DEVELOPMENT OF MULTIPLE TOOLS FOR MULTIPLE AUDIENCES

Beginning the Conversation

M-LEEaD scientists regularly share their research findings through presentations at SAB meetings. As noted, M-LEEaD scientists focus on pathways through which environmental exposures may contribute to adverse health outcomes. These presentations offer opportunities to discuss specific pathways to environmental health effects experienced by community residents in Detroit and surrounding areas. In one SAB meeting, an M-LEEaD scientist whose work focuses on OS described OS pathways as a mechanism linking air pollution (an SAB-identified priority) to adverse health outcomes.

OS is a chemical imbalance in the body where there is more reactive oxygen species (a type of ‘free radical’) than can be easily processed.¹⁵ OS underlies many pathological processes associated with air pollution,^16–20 including asthma,²¹ neurodegenerative disease,²² the metabolic syndrome,²³ cancer,²⁴ diabetes,²⁵ and obesity.²⁶ Antioxidants, when present in the body in sufficient quantities, capture reactive oxygen species to detoxify excess oxygen species.²⁷ Antioxidants include vitamin A, C, and E, beta-carotene, selenium, zinc, and various enzymes, and are commonly found in berries, beans, nuts, grains, and vegetables.²⁸ Researchers at the M-LEEaD Center and elsewhere are working to characterize risk factors, such as air pollution exposure, that affect OS and the potential of various antioxidants to reduce the adverse health effects of exposure to air pollutants and other sources of OS.^29–33

Reflecting air pollution as an SAB-identified priority, OS pathways offered an opportunity to translate this scientific information for local audiences. The SAB began to discuss how patterns of exposure to air pollution and variations in access to foods rich in antioxidants across areas of Detroit might influence the health of Detroit residents. This dialogue, which unfolded over a 2-year period, led to the development of several translational tools for various local audiences, a deeper understanding among partners of the evidence regarding OS and its patterning of risk and protective factors in Detroit, and new research questions which were developed and tested.

The First Translational Tool: OS Fact Sheet

The COEC initially developed a fact sheet titled What is Oxidative Stress? (Figure 2, Box A). This iterative process engaged SAB members with M-LEEaD scientists. Fact sheets are a simple translational tool that can be modified for diverse audiences, such as community members or policymakers. Depending on the audience, components may include topic background, key research, recommendations for individual or policy action, additional resources, and contact information.³⁴ The goal of this initial OS fact sheet was to provide a general description of OS processes, including risk factors, for public health decision makers, educators, and environmental advocates. For example, the fact sheet defines free radicals and lists examples of their sources (e.g., cigarette smoke, air pollutants). After prioritization of this fact sheet by the SAB, COEC staff worked with M-LEEaD scientists to develop a draft and to ensure scientific accuracy. Then, multiple drafts were discussed between the SAB members, COEC staff, and M-LEEaD scientists. The SAB was instrumental in shaping the content, language, and behavioral and policy recommendations included in the fact sheet. The fact sheet was produced in English and Spanish, the two predominant languages spoken in Detroit, to ensure accessibility among the COEC’s constituency groups.

Reaching Broader Audiences: Video

As the What is Oxidative Stress? fact sheet was being finalized, the SAB voiced concern that fact sheets might reach only limited audiences. After some discussion, a decision was reached among SAB members and COEC staff to create a video about OS (Figure 2, Box B) to reach a broader community audience. Videos have long been used as a tool for health promotion to reach broad audiences.^35,36 A team of students from the University of Michigan School of Public Health worked with several members of the SAB and Detroit community members to develop the video. To communicate underlying scientific concepts, the video included a description and image of oxidation causing browning of an apple to illustrate the OS process. The video goes on to describe OS in the human body, its health implications, and the heightened burden of exposure in communities of color and low-income communities, as well as protective factors and individual- community-, and policy-level strategies for reducing OS. Titled Oxidative Stress in your Everyday Life, the video was co-produced by a member of the SAB (manuscript co-author Wilkins). Local images and narrative by Detroit residents are incorporated in the video, and MLEEaD scientists reviewed the video to assure scientific accuracy. Upon completion of the video, the SAB worked with COEC staff to develop a dissemination plan for its use by multiple audiences, including community leaders, public health practitioners, and educators working with various populations. With assistance from another SAB member with experience producing health promotion videos, a discussion guide was developed to support facilitators in leading effective discussions, reviewing key scientific concepts, and making the video’s content pertinent to various Detroit neighborhoods (Figure 2, Box C).

Deepening the Dialogue: Additional Tools to Examine and Communicate the Patterning of OS Risk and Protective Factors

The development and use of the video and initial fact sheet encouraged additional dialogue among the SAB on OS pathways. Increasingly, these discussions spanned multiple levels of the social ecological model to describe patterning of OS risk and protective factors,^37,38 including individual-level health behaviors (e.g., smoking, physical activity near polluting sources) as well as more distal determinants of OS influenced by community- or policy-level factors (e.g., exposure to air pollution, availability of antioxidant-rich foods). These conversations led to development of additional community-engaged research and tools, including maps and other fact sheets that more specifically consider implications for health in Detroit.

Reflecting the increasing complexity of those conversations, COEC staff worked with SAB members and M-LEEaD scientists to develop three additional fact sheets Foods Rich in Antioxidants arose out of conversations with the SAB about the potential role of antioxidant-rich foods in protecting against air pollution’s adverse effects, and provides a list of foods rich in antioxidants (Figure 2, Box D). Air Pollution and Oxidative Stress and Air Pollution, Oxidative Stress, and Antioxidants provide additional information and visualizations of the patterning of OS risk and protective factors in Detroit, including maps, the development of which is described below (Figure 2, Boxes F and G). Reflecting the priority that the SAB and COEC place on communicating with policymakers and public health decision makers, we worked together to develop Air Pollution, Oxidative Stress & Antioxidants, directed toward decision makers with additional considerations and recommendations for policymaking.

Because SAB discussions began to emphasize the patterning of air pollution exposure and access to stores carrying healthy, antioxidant-rich foods, the SAB and COEC decided to map these features in Detroit (Figure 2, Box E). Mapping has increasingly become an effective tool for communicating local public health issues, providing opportunities for community and academic partners to integrate geographic data with on-the-ground perspectives visually.^39–43 The COEC and SAB worked together to develop and discuss several maps that displayed stationary and mobile sources of air pollution. These maps were then overlaid, for example, with density of food stores and farmers’ markets (as sources of antioxidant-rich foods) and demographic patterns in Detroit. To do this, we used ArcGIS 10.0⁴⁴ to display publicly available data from local and national datasets.^45–49 These maps emerged from conversations among M-LEEaD scientists, SAB members, and COEC staff, and reflected a joint commitment to understand the combined effects of exposures to air pollutants and variations in access to antioxidant-rich foods as these may contribute to differences in health risk within Detroit.

The SAB requested subsequent spatial analyses and enhancements to expand the use of these maps as translational tools for additional audiences. For example, maps located approximately 41,750 people as living within 200 meters of high-traffic freight corridors in Detroit in 2012, associated with well-documented air pollution exposures⁵⁰ likely to affect health through OS pathways. After discussion at an SAB meeting, the maps were refined to reflect suggestions for increasing local relevance, including further formatting and labels (Figures 3 and 4). For example, an additional map was created showing city council districts to support potential policy advocacy efforts. SAB members reflected on what the maps conveyed about their communities and who else should view them (e.g., business leaders, community-led planning groups).

Figure 3.

Original map. Air pollution exposures as contributors to oxidative stress in Detroit, Michigan.

Figure 4.

Modified map. Air pollution exposures as contributors to oxidative stress in Detroit, Michigan, with city council districts.

DISSEMINATION OF TRANSLATIONAL TOOLS

While generating this suite of tools through a multidirectional process, the MLEEaD scientists, COEC staff, and SAB members worked together to identify several outlets for dissemination intended to increase audience reach, including audiences who may not generally have scientific knowledge of environmental health topics such as OS. Audiences prioritized by SAB members included community members and health educators who can use environmental health science to inform program and policy efforts. Dissemination outlets to reach these audiences are described for each dissemination tool in Table 1, and include websites, community forums, farmers’ markets, film festivals, community organizations, and clinics. Dissemination has been facilitated and greatly enhanced by the networks in which each of the SAB member organizations is embedded, and through which they actively share the resources developed.

Table 1.

Translating the Environmental Health Science of Oxidative Stress: Outlets for Disseminating Multiple Tools to Diverse Audiences

Tool	Translation of Scientific Topics	Dissemination Outlets
Fact sheets	OS, including its risk factors, health effects, and preventative measures	Posted online on M-LEEaD website & Partnership for Environmental Public Health (PEPH) Resource Center
	Dietary intake of antioxidants as preventative factor	Over 750 copies distributed to clinics, health departments, and community-based organizations throughout Detroit
	Air pollution exposure as risk factor	Over 250 copies of Foods Rich in Antioxidants distributed to the public at the Detroit Eastside Farmer’s Market, Northwest Detroit Farmer’s Market, and the Community Health and Social Services’ Mercado
Video and discussion guide	OS, including its risk factors, health effects, and preventative measures	Posted online on M-LEEaD website, PEPH Resource Center, and YouTube (nearly 400 views as of May 2015)
		Presented November 2013 at the American Public Health Association’s Annual Meeting’s Film Festival to public health practitioners and scholars
Maps	Geographic distribution of preventative and risk factors	Enlarged and posted during a Detroit Air Pollution Community Forum attended by over 100 community members, environmental activists, and decision-makers, as well as Linda Birnbaum, Director of NIEHS58
		Enlarged and displayed at the Detroit Eastside Farmer’s Market, Northwest Detroit Farmer’s Market, and the Community Health and Social Services’ Mercado
		Integrated into two fact sheets: Air Pollution and Oxidative Stress and Air Pollution, Oxidative Stress, and Antioxidants

M-LEEaD, University of Michigan Lifestage Environmental Exposures and Disease.

The COEC also disseminated these OS tools in the context of policy trainings on environmental health issues. During training workshops, community and academic trainers use a model developed by the Detroit Community-Academic Urban Research Center,⁵¹ which entails an in-depth overview of policy, advocacy, and related communication techniques, power mapping, and development of a communication strategy. COEC evaluation has documented that workshop participants subsequently incorporated information about environmental health exposures in their work with decision makers on local land use issues.⁵²

Multidirectional dialogue related to these multiple tools has also led to further research, disseminated through peer-reviewed manuscripts and conference presentations. Growing out of COEC and SAB discussions, M-LEEaD scientists empirically tested the joint effects of particulate air pollution and dietary antioxidant intake on blood pressure using air monitoring and health survey data from Detroit.²⁹ Also, maps developed through this iterative process were presented to local and national audiences including the Detroit Air Pollution Community Forum,⁵³ local farmers’ markets, and American Public Health Association Annual Meetings. They are also being used as part of a process to develop a public health action plan designed to reduce exposure to air pollution and mitigate its adverse health effects in Detroit, involving several members of the SAB and M-LEEaD teams.

DISCUSSION

The collaborative process described here provides an example of the emergence of a set of integrated tools for translating environmental health science, informed through dialogue among representatives from community-based and environmental organizations, health service providers, and academic researchers. Over time, SAB dialogue contributed to the development of increasingly sophisticated and nuanced tools that reflected community priorities. These tools were gradually more targeted to the local patterning of risk factors and protective resources, with potential to inform local program and policy decisions. Although the term ‘oxidative stress’ may be unknown to many, our tool development and dissemination process related it to crosscutting issues that concern communities, for instance, both air quality and food access in the context of OS in Detroit. The SAB began with an interest in air pollution and learned of the potential role of antioxidants in reducing its effects on OS. They were instrumental in developing translational tools, and in disseminating fact sheets at local clinics, health departments, and farmers’ markets to encourage dietary intake of antioxidant-rich foods to protect against the adverse effects of exposure to air pollutants. The iterative, multidirectional nature of this process reflects movement beyond unidirectional translational science to more comprehensively address community priorities and demonstrate the relevance of findings within affected communities.⁵⁴ Further, engagement of disproportionately affected communities, and practitioners who work most closely with them, is central to identifying, implementing, and advocating for effective evidence-based interventions and policy decisions to address health disparities.^55,56

We describe a continuous multidirectional community-academic dialogue that strengthened the translation of environmental health science of OS by communicating multiple determinants of health. Recognizing the diverse factors that contribute to risk helps to identify multiple points at which to intervene to promote health and address excess risks and corresponding health disparities.⁵⁷ For instance, fact sheets describe several individual behavior changes (e.g., intake of antioxidant-rich foods) as well as community level interventions (e.g., vegetated buffers around pollution sources) that may be implemented to reduce OS for Detroit residents. Similarly, the video and corresponding discussion guide each examine individual as well as policy actions to reduce OS, and the maps illustrate land use patterns as determinants of health underlying OS. Although these tools may not be exhaustive in capturing the many pathways linking social and physical environments to OS, they attempt to illustrate multiple pathways and potential points of intervention to promote health.

Recognizing that these tools communicate environmental health science within a particular local context, some of the tools presented in this manuscript may not be immediately ready for dissemination by other COECs or community-academic partnerships. However, the process described herein may be useful in other settings and by other groups who share a commitment to ensuring that program and policy decisions are informed by environmental health science and guided by community priorities. Despite its complexity, these examples that illustrate translation of OS and its risk and protective factors, may transfer well to a variety of similarly complex, multidimensional environmental health issues prioritized by communities.

The reach or effectiveness of these tools and their ability to create corresponding policy, community, and individual changes to improve population health over time largely remain to be evaluated. Although we cannot share results of formal evaluation, we provide examples of how key specific scientific issues were translated for dissemination through images, video narrative, maps, and text, including their potential reach in doing so. The iterative nature of our process invited opportunities to continuously improve tools. For example, based on ongoing SAB discussions, our video was developed to address limitations of fact sheets, and the video discussion guide to expand use of the video as a translational tool. Creative possibilities for tool development are nearly limitless, but time and financial resources were real limitations in determining each next step.

CONCLUSIONS

The collaborative and multidirectional process described unfolded over time, resulting in a deepening of the dialogue regarding translational science. The diversity of tools that emerged from this process reflects both the need to communicate effectively with different audiences, and the emergence of increasing depth within these dialogues as they unfolded over time. SAB members informed the tools, assuring that they reflected Detroit and Southeast Michigan priorities and health inequities, providing relatable and specific information to diverse audiences. The ongoing use of these tools supports education, research, and policy advocacy efforts—from new empirical studies to participation in film festivals to policy trainings. This case study suggests that structures and processes that support long-term collaborative engagement between community and academic partners effectively contribute to translation of complex environmental health topics within community settings while simultaneously informing future research.