Environmental Health Knowledge Does Not Necessarily Translate to Action in Youth

{"Background": "Environmental hazards contribute to over 12 million deaths globally each year, with youth being particularly vulnerable to conditions such as asthma, ADHD, and poor cognitive functioning. Economic costs of these preventable conditions exceed $50 billion annually for American children. Despite the US Healthy People 2030 environmental health goals, environmental health education is rarely paired with general health education in K-12 schools, and students' comprehension is typically not tested. Prior research suggests that while youth can identify environmental concerns, they often feel powerless to act, particularly younger participants. The relationship between knowledge, attitudes, self-efficacy, and behavior is complex and likely varies by age, necessitating further study.", "Methods": "This was a cross-sectional, descriptive survey study of a convenience sample of Midwestern children and adolescents aged 9-18 years recruited from three well-resourced schools in the Cincinnati, Ohio metropolitan area. The study was approved by the Cincinnati Children's Hospital Medical Center IRB. The survey was adapted from prior work by Naquin et al. and assessed knowledge, attitudes, and behaviors, with a self-efficacy subscale added for participants aged 15-18. Responses were recorded on a 5-point Likert scale. The survey also included four open-ended questions. Internal consistency (Cronbach's alpha) for the overall surveys ranged from 0.87 to 0.89. Of 503 respondents, 47 were excluded for missing subscale responses and 4 for missing age data, yielding 452 surveys for qualitative analysis and 438 for quantitative analysis. The sample had 80% power to detect differences as small as 3.74 units between scores given an SD of 27.7 at alpha=0.05.", "Key Results": "Participants had a mean age of 13.6\u00b12.6 years; 59.3% were female, 90.9% were white, 87.4% lived in suburban areas, and 13.7% reported a history of asthma. Overall quantitative knowledge scores were moderate (mean 66.2\u00b120.6), with higher scores in the two older age groups compared to the 9-11 group (p=0.001 and p<0.001). Behavior scores were substantially lower (mean 29.03\u00b127.7) and lowest in older age groups (p<0.001). Only 30 (6.7%) participants provided a \"very good\" definition of health encompassing physical, mental, and social domains, and only 9 included the environment in their definition of health. Air pollution was the most frequently cited environmental concern. Knowledge correlated only weakly with behavior overall (r=0.22, p<0.001), while behavior correlated moderately with attitudes (r=0.54, p<0.001) and self-efficacy (r=0.51, p<0.001). Knowledge correlated moderately with attitudes (r=0.38, p<0.001) and self-efficacy (r=0.47, p<0.001). In the 15-18 age group, participation in environment-related classes, activities, or clubs was significantly associated with higher behavior scores (26.2\u00b125.3 vs 16.3\u00b123.4, p=0.006), knowledge (73.9\u00b120.9 vs 65.1\u00b119.1, p=0.003), attitude (54.5\u00b120.8 vs 44.6\u00b123.3, p=0.003), and self-efficacy (median 75.0 vs 66.6, p=0.02) scores. Participants with both parents employed had higher behavior scores (p=0.03) and self-efficacy scores (p=0.045). Those with asthma had elevated self-efficacy scores (p=0.007). Only one of six teachers reported integrating environmental health into their teaching.", "Clinical Implications": "Findings indicate that environmental health knowledge alone is insufficient to drive pro-environmental behavior in youth; attitudes and self-efficacy are more strongly linked to behavior and may be more effective intervention targets. Targeted, locally focused environmental health education programs\u2014particularly those engaging students in extracurricular activities, citizen science, and community-based participatory approaches\u2014are associated with improved knowledge, attitudes, self-efficacy, and behavior. Because youth rarely connect environmental concerns to local or personal health contexts, programs should explicitly link environmental issues to physical, mental, and social health outcomes. Given that socioeconomic status is positively associated with environmental health knowledge, under-resourced communities may benefit most from such programming. Future educational interventions should be co-created with community partners and tailored to local environmental health risks, and their impact on knowledge, attitudes, self-efficacy, and behavior should be directly evaluated."}