Q&A: Research Shows Struggles to Improve Indoor Air Quality in Childcare Centers

The American Journal of Managed Care^® (AJMC^®) dicussed the prevalence of poor indoor air quality in childcare facilities with Joshua Steinberg, MD, assistant professor of pediatrics at the Medical College of Wisconsin, and Erin Lee, a clinical research coordinator at the Medical College of Wisconsin. Their study entitled, "Assessment of Indoor Air Quality and Cleaning Behaviors in Urban Child Care Facilities" found common exceedences of threshold volatile organic compounds (VOC) and carbon dioxide (CO2) concentrations, particularly in home-based childcare centers. The abstract was released through the American Academy of Allergy, Asthma & Immunology (AAAAI), which canceled its 2020 Annual Meeting due to COVID-19.

AJMC^®: A Canadian Medical Association journal study, published in February, found that frequent exposure to cleaning products in early childhood was linked with asthma and wheezing. Did this study influence your decision to analyze indoor air quality of urban childcare facilities, in particular?

Steinberg: I am familiar with the article. This project was initiated much earlier than that article, given less strong evidence at that time, but there is a wide appreciation that indoor air quality is poor and that this particular population is the most susceptible to the development of asthma and other wheezing disorders. We already previously identified, the EPA has identified as well, that improving air quality by reducing irritants such as chemical volatile organic chemicals, or irritants, or particulates generated within an institutional environment, is something that should be done anyway, even though we didn't have this conclusive data of the influence upon development of asthma.

AJMC^®: What did the greener cleaning educational program involve?

Lee: It was designed as a 2-hour program for childcare staff. It was meant to be interactive and written at basically a third-grade reading level. We did a broad overview of asthma and how indoor air quality, specifically air quality factors related to cleaning products and related to air quality factors if you're not cleaning, how those would affect asthma. Then we went through an overview of what the most health-concerning chemicals and product classifications were, and what sort of green alternatives were available to get that same cleaning chore done without buying those more concerning chemicals. We talked through essential oils and some of the effects essential oils can have on people that have asthma. Then we have a set of recipes that basically use baking soda and vinegar as the main cleaning components. There are a set of recipes that we went through and helped people learn how to make themselves, to replace some of the commercial cleaners that are often used.

AJMC^®: Why do you think this program resulted in negligible improvements of indoor air quality?

Lee: I have a gut feeling on a couple of things. One is that, especially with the larger childcare centers, we were teaching to childcare staff. It became clear as we were doing this teaching that many of those larger childcare centers were hiring cleaning companies to do all of the cleaning. The education we were providing was not being shared with the people who are actually doing the cleaning in those centers. That was one of the big things that I thought was causing a barrier. It was also very quick. I think in a very fast 4-month intervention, where you're only really being face-to-face with all of the staff for about 2 hours, there isn't enough support to support behavior change. We did not provide any supplies or starter kits of any of the materials that we were promoting to use. Mainly for me, those are the 3 things that I thought inhibited some of the behavior change we were hoping for.

AJMC^®: Are there any plans to revise the program and implement it, or test it, in other areas with poor air quality to see if uptake will increase?

Steinberg: We have submitted a grant proposal to focus still on childcare environments, because we do feel that's the the population that is the least studied presently and also with the most opportunity for health effects. Usually by age 5, many children already have existing asthma-like symptoms. There are existing policies regarding air quality, except for a few areas in Europe and very few states. For the most part, however, indoor air quality is not regulated at all in childcare environments. Instead of focusing just on green cleaning, we're hoping to focus more on alignment with national guidelines and policies, which already exist. Presently, as best we can tell, there's negligible, if any, knowledge of the policies or any guidance on how to actually implement those policies. I think a little bit more qualitative element for each facility, and also focising on more longitudinal help to identify the obstacles that each childcare facility is having, will help improve their air quality.

Lee: We're trying to potentially link the indoor air quality that we're measuring to symptoms of the children that are in that childcare environment. Along with all of the policy and the support pieces that Dr. Steinberg was talking about, I think it's important to be clear that we're trying to connect indoor air quality to the health effects.

AJMC^®: Your abstract stated that observed smoke, mold, perfumes, spray air freshener, and bleach use were common, along with exceedances of threshold volatile organic compounds and CO2 concentrations, particularly in residential centers. Can you outline the risks associated with these findings?

Steinberg: One of the novelties of our study was that we used consumer grade air quality monitors. To be able to deploy them for continuous monitoring in these facilities for very little money, the monitors at present aren't able to distinguish each volatile organic chemical separately. It's a combined measurement. We're not entirely sure exactly which of those components are the most critical, or one that's different in each facility. That limited our ability for output; to be able to understand exactly what each childcare was exposed to. Because they're combined, unfortunately and especially for volatile organic chemicals, even though that's pretty much the most common sensor in almost all the consumer monitors, we don't really have the data on which components of that are actually health relevant. Certainly we know for formaldehyde, for health impairments, and for asthma, for ozone and other chemicals such as that. But we don't really know what the impact of a composite is upon health at this time, especially not upon asthma. But at the present time, that's one of the easiest measurements we are able to make. It's a problem kind of throughout the whole field.

Lee: We were looking for a baseline description of what was going on in the childcare environment. There wasn't really anything that we had found to show what you would even find if you tried to measure air quality. We were looking at, what are people doing that might produce changes in air quality levels? What were the actual air quality levels? Were we finding exceedances? It was very much a baseline study.

Steinberg: It identified what baseline behaviors are used. Most of the facilities did use air fresheners, which are not recommended for the national criteria. Many of the facilities actually did the cleaning work while the children were attending. Perfume exposure and use in homes was also quite common. A lot of odorants were commonly used. Bleach use is required by law, for sanitation purposes, but dilution and when it's applied, and how it's applied, was one of our questions too, and we learned quite a bit about that as well.

AJMC^®: You also found that the brief educational interventions did not appear sufficient to alter cleaning behaviors. As you mentioned, indoor air quality is largely unmonitored. Do you think that more regulation of indoor air quality is needed to prompt these more proactive countermeasures?

Lee: It's part of why our next study is going to have a strong policy focus. Some policy recommendations already exists nationally. However, the recommendations don't really come with any kind of funding or support to make the changes happen at a local level.

Steinberg: A lot of these childcare centers, especially the residential ones, work on fairly shoestring budgets. We did identify that for most facilities, especially the family facilities, the small family run, home-based facilities, time was their biggest concern with implementing any new change. That being said, regulation really does define a lot of the behaviors that are happening in childcare facilities. That's their guidebook. It is a well-established mechanism for eliciting change within childcare facilities regarding safety issues, appropriate staffing issues, and a whole lot of other factors. However, again, indoor air quality, despite being part of those guidelines, is, for the most part, not part of any state's regulations at the present time. We don't know if policy, whether voluntary or regulation-based, would be more effective mechanisms for eliciting some change to the air quality.

AJMC^®: Were there any results that stood out or highlights from the study you want to share?

Lee: What I thought was really quite interesting was when we averaged all of the indoor air quality measures during the day, as you went hour by hour throughout the day, as you got to toward the end of the day, levels increased of VOC and CO2. Those same levels also increased over the course of the week. By Thursday and Friday, the levels were higher than on Monday or Tuesday. This pushed us in the direction of looking at occupancy hours. When we pulled out all of the non-occupancy hours from the data, we did find exceedances for the CO2 and the total organic compound measurements, but also for PM 2.5 (fine particulate matter). For PM 2.5, 8% of the time there were exceedances. For carbon dioxide, it was about 37% of the time that there was exceedances. For total VOC, 31% of the time there were exceedances.

Steinberg: Because many of these facilities are quite under-resourced, in the future we are looking at whether active intervention with an air cleaning machine, or more passive interventions with policy changes will be effective. For example, would just improved ventilation systems, either built into their system or just opening windows more often, based on the air quality measurements be a better intervention or more feasible intervention?