Barriers and Facilitators to Early-life Wildfire Smoke Protection in a Rural Population: The Role of Community in Research and Public Health Practice.

Background: Millions of U.S. families are exposed to unhealthy levels of wildfire smoke (WFS) annually. Interventions to reduce the impacts of WFS on child health are urgently needed, especially for families in vulnerable communities, where WFS exposure is high yet resources and opportunities for self-protection are limited. Little is known about parents' current engagement in protective behaviors, a knowledge gap that challenges development of feasible and acceptable interventions. We aimed to address this gap in a rural community in Washington State with high concerns about WFS and child health. Methods: We conducted community meetings and utilized an existing framework of behavioral change to draft a conceptual model of barriers and facilitators of WFS protective actions. Using this model, we identified hypothesized determinants of protective behaviors (N = 11) that could be characterized by surveying parents about perceptions of WFS and experiences in past fires. Surveys were administered by local college students at community events and online, in English and Spanish. Linear regression with robust standard errors estimated associations between z-scores of determinants of action and total action score, a sum of frequencies of protective actions (N = 6) taken in past smoke events. Predictors of frequencies of each specific action were also characterized in exploratory analyses. Results: Of N = 199 participating parents, 84.8% were Hispanic, 55.3% were born in Mexico, and 58.8% had an annual income < 40K. The most frequent protective action was staying indoors, and the least was leaving the region, with 54.8% and 1.5% reporting doing so "often", respectively. Impacts on child health in past WFS events and observations of other community members taking action were most strongly associated with action scores (ß=0.91 [95% CI: 0.50, 1.31] and 0.67 [95% CI: 0.16, 1.18] per standard deviation, respectively). Chronic health conditions, general WFS knowledge, and practical knowledge about WFS mitigation also predicted more actions. Conclusions: These novel data identified facilitators of protective behaviors that that can be targeted in future interventions. The observed importance of social norms is consistent with community members' descriptions of a local culture of