What about behaviours in swimming pools? Results of an Italian multicentre study

Health-related behaviors and associated factors among swimming pool users in Kombolcha Town, Northeastern Ethiopia

Objective

Unhealthy behaviors during swimming exposes at risk of recreational water-associated diseases. The swimming pool users are the high-risk group for getting and transmitting the diseases. Thus, conducting a study on swimming pool users' health-related behaviors is crucial to prevent the transmission of recreational water-associated diseases.

Methods

This cross-sectional study was employed among 140 randomly selected swimming pool users from April 1st to 30th, 2021 in Kombolcha Town. Data were collected using an interviewer-administered questionnaire and an on-the-spot-observational checklist. The collected data were entered to EpiData version 4.6 and exported to SPSS version 25 for data cleaning and analysis. Determinants of health-related behaviors were identified by using a multivariable logistic regression model at a p-value < 0.05.

Results

The overall good health-related behavior among swimming pool users was 41.4% (95% CI: 33.6-49.3). Out of the total 140 swimming pool users, 55% (95% CI: 46.4-62.9) had good knowledge about health risks during swimming. Good knowledge about health risks during swimming (AOR = 9.64; 95% CI: 3.14-29.61), educational status of college or above (AOR = 6.52; 95% CI: 1.76-24.10) and age being > 28 years (AOR = 6.49; 95% CI: 2.34-18) were factors significantly associated with good health-related behaviors.

Conclusion

The finding of the study showed that the majority of the swimming pool users had poor health-related behaviors. Thus, Kombolcha Town Health Bureau and swimming pool managers should give attention to this population to enhance health-related behaviors through addressing the significant predictors.

Determinants of bather hygiene in public swimming pools: a mixed-methods analysis of online discussion comments

Swimming in public pools can expose bathers to microbiological (e.g., Cryptosporidium) and chemical (e.g., disinfection by-product) hazards, which can lead to recreational water illness. Adequate hygienic behaviours among bathers are important to reduce these risks. However, prior studies have found low compliance with pre-swim showering and avoidance of urinating in pools. We conducted a mixed-methods analysis of online discussion comments to identify key determinants of these two behaviours. We identified relevant discussion threads on Reddit, Quora, and swimming forums. Identified comments were classified as having a positive or negative sentiment towards the behaviour, and they were thematically analyzed according to the Theoretical Domains Framework (TDF). We analyzed 986 comments from 45 threads; 49.8% of comments were classified as expressing a positive sentiment towards the behaviour. Positive sentiments were more commonly expressed towards pre-swim showering compared to avoidance of urinating in pools (60.1 vs. 47.1%). Eleven themes were identified across the following eight TDF domains: beliefs about consequences (n = 362 comments), social influences (n = 298), beliefs about capabilities (n = 240), social/professional role and identity (n = 144), knowledge (n = 138), emotions (n = 137), reinforcement (n = 78), and environmental context and resources (n = 33). Results can help to inform targeted educational and outreach strategies with bathers to encourage increased adoption of hygienic behaviours.

Waterborne disease outbreaks in treated recreational water facilities: a Socio-Ecological Model perspective

Treated recreational water facilities, including swimming pools and water play parks, have often been implicated in infectious disease outbreaks. Addressing this problem is complex due to the multiple and interrelated factors contributing to outbreaks in these settings. These factors may relate to inappropriate behaviours of users and operators, lack of and inconsistent regulation of these facilities, insufficient facility maintenance, and problems associated with the design of these facilities. Given the complexity of this issue, we argue that the Socio-Ecological Model (SEM) provides a useful framework to help identify the multi-level influences and factors that have implications for designing interventions to prevent this public health problem, whilst assisting in guiding future research in this area. We apply the SEM to the current literature to help identify the influences and factors contributing to infectious disease outbreaks in treated recreational water facilities to support this argument. We also identify several gaps in the existing research that would benefit from further examination to help prevent infectious disease outbreaks in treated recreational water facilities such as public swimming pools and water play parks.

Ethylhexyl methoxycinnamate and butyl methoxydibenzoylmethane: Toxicological effects on marine biota and human concerns

Ethylhexyl methoxycinnamate (EHMC) (CAS number: 5466-77-3) and butyl methoxydibenzoylmethane (BMDM) (CAS number: 70356-09-1) are important sunscreens. However, frequent application of large amounts of these compounds may reflect serious environmental impact, once it enters the environment through indirect release via wastewater treatment or immediate release during water activities. In this article, we reviewed the toxicological effects of EHMC and BMDM on aquatic ecosystems and the human consequences. According to the literature, EHMC and BMDM have been detected in water samples and sediments worldwide. Consequently, these compounds are also present in several marine organisms like fish, invertebrates, coral reefs, marine mammals, and other species, due to its bioaccumulation potential. Studies show that these chemicals are capable of damaging the aquatic beings in different ways. Further, bioaccumulation studies have shown that EHMC biomagnifies through trophic levels, which makes human seafood consumption a concern because the higher position in the trophic chain, the more elevate levels of ultraviolet (UV) filters are detected, and it is established that EHMC present adverse effects on the human organism. In contrast, there are no studies on the BMDM bioaccumulation and biomagnification potential. Different strategies can be adopted to avoid the damage caused by sunscreens in the environment and human organism. Two of them include the use of natural photoprotectors, such as polyphenols, in association with UV filters in sunscreens and the development of new and safer UV filters. Overall, this review shows the importance of studying the impacts of sunscreens in nature and developing safer sunscreens and formulations to safeguard marine fauna, ecosystems, and humans.

Performance indicators for aquatic centres in Canada: Identification and selection using fuzzy based methods

Aquatic centres (ACs) are becoming exceedingly popular in the urban agglomerations of cold climate countries like Canada but functioning without assessing the state of their sustainability performance. Previous studies examined health and safety, water and indoor air quality, and energy consumption aspects without aiming at the holistic sustainability performance assessment. The present research is the first systematic effort for benchmarking of ACs. A hierarchical-based framework arranged 81 performance indicators to appraise the key components, including water management, indoor environment, personnel, service quality, energy, social, and operations. Fuzzy AHP and fuzzy mean clustering methods evaluated the identified PIs based on the opinion of experts (from Canadian aquatic centres) on their importance, measurability, and understandability. Finally, the selection process ranked a set of 63 most suitable PIs under 14 sub-criteria. Fuzzy-based methods efficiently handled the subjective scoring process and the difference of opinion among the experts. The criteria performance indices inform the top-level management while the sub-indices stipulate the operations management for honing in the lacking indicators. Using the selected PIs, the AC's management can allocate the available resources for both the short-term (e.g., efficient response to complaints) and long-term (e.g., replacing failed manually operated fixtures with the sensor-operated ones) improvement actions. The selected PIs will enhance the sustainability of ACs in Canada and other cold regions around the globe through a structured benchmarking process.

Identification of avobenzone by-products formed by various disinfectants in different types of swimming pool waters

The increased use of sunscreens and other cosmetics containing UV filters causes human and environmental burden. Avobenzone is a widely used UV filter. In its pure form it is known to undergo several transformations including photo-isomerisation, photodegradation, and halogenation. Over 60 disinfection by-products were identified as transformation products of avobenzone in different disinfection reactions of chlorination and bromination in fresh and seawater. Two occasional samples of swimming pool water demonstrated the presence of some of these by-products at noticeable levels as judged by GC-MS peak areas. Although the toxicity of the majority of these products remain unknown, chlorinated phenols and acetophenones are known to be rather toxic. Aquatic bromination of avobenzone resulted in the identification of 33 disinfection by-products (DBPs). Many of them contain bromine in the molecular structure. Addition of copper salt slightly decreases conversion rate simultaneously increasing the levels of major brominated products. Photostability of 3 commercial sunscreen products (solar protection factor 30) containing avobenzone was studied under different experimental conditions including UVA/UVB, UVC photostimulation and chlorination. The commercial sunscreen products have completely different enhancing and inhibitory effect on avobenzone degradation under UVC light. The complex composition of commercial products caused also a protective shield in case of chlorinated solutions of commercial formulations exposed to chlorine and UVA/UVB light at the same time.

The potential of the organic micropollutants emission from swimming accessories into pool water

The potential leaching of organic micropollutants from swimming accessories was studied in the laboratory experiment. Seventeen different swimming accessories have been placed in various water matrices under different conditions in order to reproduce the actual environmental conditions of swimming pool water. The presence of micropollutants in water samples, after the exposure of swimming accessories, was assessed using indirect indicators (Total Organic Carbon and Phenol Index) and directly using a gas chromatograph coupled with a mass spectrometer with electron ionization. A wide range of organic compounds emitted from swimming accessories have been identified. The most common in tested samples was isophorone. The frequency of its occurrence in 50 swimming pools located in Poland was equal to 89% in concentrations ranged from 0.75 to 1.01 µg L^-1 (below the concentration of 40 µg L^-1, which is estimated to increase the cancer risk). Content of combined chlorine (1.52-3.16 mgCl₂ L^-1) in chlorinated matrices indicated a high potential for disinfection by products (DBPs) formation from organic matter emitted into pool water from swimming accessories. Ten of seventeen tested samples showed the toxic effect, measured as the bioluminescence inhibition of bacteria Aliivibrio fischeri.

Occurrence and formation of disinfection by-products in the swimming pool environment: A critical review

Disinfection of water for human use is essential to protect against microbial disease; however, disinfection also leads to formation of disinfection by-products (DBPs), some of which are of health concern. From a chemical perspective, swimming pools are a complex matrix, with continual addition of a wide range of natural and anthropogenic chemicals via filling waters, disinfectant addition, pharmaceuticals and personal care products and human body excretions. Natural organic matter, trace amounts of DBPs and chlorine or chloramines may be introduced by the filling water, which is commonly disinfected distributed drinking water. Chlorine and/or bromine is continually introduced via the addition of chemical disinfectants to the pool. Human body excretions (sweat, urine and saliva) and pharmaceuticals and personal care products (sunscreens, cosmetics, hair products and lotions) are introduced by swimmers. High addition of disinfectant leads to a high formation of DBPs from reaction of some of the chemicals with the disinfectant. Swimming pool air is also of concern as volatile DBPs partition into the air above the pool. The presence of bromine leads to the formation of a wide range of bromo- and bromo/chloro-DBPs, and Br-DBPs are more toxic than their chlorinated analogues. This is particularly important for seawater-filled pools or pools using a bromine-based disinfectant. This review summarises chemical contaminants and DBPs in swimming pool waters, as well as in the air above pools. Factors that have been found to affect DBP formation in pools are discussed. The impact of the swimming pool environment on human health is reviewed.

Health-Related Behaviors in Swimming Pool Users: Influence of Knowledge of Regulations and Awareness of Health Risks

Background: Swimming pool attendance exposes users to infection and chemical risks that could be largely reduced with the adoption of healthy behaviors. This study aims to investigate if the knowledge of swimming pool regulations and awareness of health risks can be associated with users’ health-related behaviors. Methods: A cross-sectional study was conducted using self-administered questionnaires to collect data from two different target groups of swimming users: 184 adults and 184 children/adolescents. The association between specific variables and patterns of behaviors and knowledge was assessed through multivariate logistic regression models. Results: Although more than 80% of both groups declared they knew the regulations, compliance with healthy behaviors was often unsatisfactory, especially in adolescents and youth. In the children/adolescents group, healthy behaviors significantly increased with the frequency of attendance per week. In both groups, compliance increased with educational level (of parents for children/adolescents), while no positive association was observed between viewing the regulations and adopting appropriate behaviors. In the adult group, a higher knowledge/awareness of health risks was related to decreased odds of at least one unhealthy behavior. Conclusions: Guaranteeing the public display of regulations in swimming facilities is not sufficient to promote and change health-related behaviors. Much more attention should be given to educational interventions aimed to increase knowledge of health risks and the awareness that bathers are directly responsible for their own well-being.

Occurrence and simulation of trihalomethanes in swimming pool water: A simple prediction method based on DOC and mass balance

Trihalomethanes (THM) are the most typical disinfection by-products (DBPs) found in public swimming pool water. DBPs are produced when organic and inorganic matter in water reacts with chemical disinfectants. The irregular contribution of substances from pool visitors and long contact time with disinfectant make the forecast of THM in pool water a challenge. In this work occurrence of THM in a public indoor swimming pool was investigated and correlated with the dissolved organic carbon (DOC). Daily sampling of pool water for 26 days showed a positive correlation between DOC and THM with a time delay of about two days, while THM and DOC didn't directly correlate with the number of visitors. Based on the results and mass-balance in the pool water, a simple simulation model for estimating THM concentration in indoor swimming pool water was proposed. Formation of THM from DOC, volatilization into air and elimination by pool water treatment were included in the simulation. Formation ratio of THM gained from laboratory analysis using native pool water and information from field study in an indoor swimming pool reduced the uncertainty of the simulation. The simulation was validated by measurements in the swimming pool for 50 days. The simulated results were in good compliance with measured results. This work provides a useful and simple method for predicting THM concentration and its accumulation trend for long term in indoor swimming pool water.

Occurrence and human exposure of parabens and their chlorinated derivatives in swimming pools

As an emerging group of endocrine-disrupting chemicals, parabens have attracted growing attention due to their potential effects on human health. In the present study, the occurrence and distribution of eight parabens, four chlorinated parabens, and their common hydrolysis product, p-hydroxybenzoic acid (PHBA), were investigated in 39 swimming pools in Beijing, China. Methyl paraben and propyl paraben were the predominant compounds in swimming pools, accounting for 91.2 % of the total parabens. It is noteworthy that octyl paraben, a paraben with longer chain, was firstly detected in this study. There were several factors affecting the levels of parabens among the 39 swimming pools. The concentrations of parabens and chlorinated derivatives detected in indoor pools (144 ng L(-1)) were roughly 20-fold higher than those in outdoor pools (6.78 ng L(-1)). Hotel pools appear to present higher level of target compounds (361 ng L(-1)) than that in health club (228 ng L(-1)), municipal (130 ng L(-1)), school (75.6 ng L(-1)), and community pools (63.0 ng L(-1)). Moreover, the level of these compounds in pools during weekends (174 ng L(-1)) was much higher than that during weekdays (52.3 ng L(-1)). The dynamics of target compounds were also investigated to provide a general trend of the level of parabens in a school indoor swimming pool during a 14-week period. Human exposure assessment was conducted to estimate the potential risk of exposure to parabens and their chlorinated derivatives in swimming pools. Considering the total exposure dose of multiple parabens, human exposure to parabens from the water of swimming pools is negligible. However, the threat of these parabens to children in swimming pool should be concerned.

Chemical contaminants in swimming pools: Occurrence, implications and control

A range of trace chemical contaminants have been reported to occur in swimming pools. Current disinfection practices and monitoring of swimming pool water quality are aimed at preventing the spread of microbial infections and diseases. However, disinfection by-products (DBPs) are formed when the disinfectants used react with organic and inorganic matter in the pool. Additional chemicals may be present in swimming pools originating from anthropogenic sources (bodily excretions, lotions, cosmetics, etc.) or from the source water used where trace chemicals may already be present. DBPs have been the most widely investigated trace chemical contaminants, including trihalomethanes (THMs), haloacetic acids (HAAs), halobenzoquinones (HBQs), haloacetonitriles (HANs), halonitromethanes (HNMs), N-nitrosamines, nitrite, nitrates and chloramines. The presence and concentrations of these chemical contaminants are dependent upon several factors including the types of pools, types of disinfectants used, disinfectant dosages, bather loads, temperature and pH of swimming pool waters. Chemical constituents of personal care products (PCPs) such as parabens and ultraviolet (UV) filters from sunscreens have also been reported. By-products from reactions of these chemicals with disinfectants and UV irradiation have been reported and some may be more toxic than their parent compounds. There is evidence to suggest that exposure to some of these chemicals may lead to health risks. This paper provides a detailed review of various chemical contaminants reported in swimming pools. The concentrations of chemicals present in swimming pools may also provide an alternative indicator to swimming pool water quality, providing insights to contamination sources. Alternative treatment methods such as activated carbon filtration and advanced oxidation processes may be beneficial in improving swimming pool water quality.