Academic–community partnership in Appalachia logging incidents in a “stink diary” and to record incidents of visible pollution with phone calls to each other. They also col­ lected “swipe” samples from their homes and porches and paid for the metal analyses of these samples. In 2000, they wrote a letter to former Ohio Senator Mike DeWine, who petitioned the Agency for Toxic Substances and Disease Registry (ATSDR) to evaluate the health impacts from air pollution. Two years later, the ATSDR installed a total suspended particulate air monitor about 4.5 miles north/ northwest of EMI, Inc., and in 2003 held a community meeting to assess the commu­ nity’s concerns regarding air quality. Over the next several years, the ATSDR worked with the Ohio EPA to set up additional monitoring sites. The intermediate followu­p and report ­ ing from these agencies left the community feeling frustrated with the slow progress and the lack of information to the community. During meetings with the federal agencies, the community was given information that was occasionally contradicted in other forums, so the community felt like “human subjects in an uncontrolled experiment.” In addi­ tion, tensions were growing between NCA and EMI, Inc. The community partner and other concerned community members had made many unsuccessful attempts to meet with EMI, Inc. management, who quickly dismissed their concerns and accused NCA of “pointing fingers.” NCA’s determination to find answers to their questions about Mn exposure led them to seek help from Ohio Citizen Action (OCA). OCA is a nonpartisan grassroots consumer advocacy organization devoted to organizing and implementing community­driven cam ­ paigns that motivate major industries to take steps to reduce and prevent pollution emit­ ted from their facilities (Ohio Citizen Action 2011). In June 2006, NCA, along with OCA, released a “Citizen’s Audit of Eramet Marietta” (Neighbors for Clean Air 2006) during a press conference held at the site of a newly installed ATSDR air monitor located in close prox­ imity to the ferromanganese refinery. The Cincinnati­ based OCA director at the time invited the first author (E.N.H.) to the press conference. OCA had accessed University of Cincinnati (UC) environmental health exper­ tise previously, but this was the first contact E.N.H. had with that organization. During the press conference, she conversed with many community residents who expressed their numerous concerns and thoughts about their environmental exposure. As an academic, E.N.H. recognized the tremendous opportu­ nity and assembled an academic research team to address the concerns of the community. The community offered to identify the health impacts, if any, of air Mn exposure on the neurodevelopment of children. Perspective from the academic researcher. Manganese (Mn) is ubiquitous in the environ­ ment and occurs naturally in soil, air, water, and food. Unlike other metals, such as lead and mercury, Mn is an essential trace element required for normal growth and development, playing a key role in enzyme metabolism, immune function, bone growth, neurologic development, blood sugar metabolism, diges­ tion, and reproduction (Aschner and Aschner 2005; Erikson and Aschner 2003). Mn defi­ ciency is extremely rare in humans, but it has been suggested as an underlying factor in skeletal abnormalities and osteoporosis (Keen and Zidenberg­Cherr 1996) and seizure activity (Papavasiliou et al. 1979). Adequate intake of Mn is found in the diet, and the Food and Nutrition Board of the National Research Council has provided estimated safe and adequate daily dietary intake (ESADDI) levels for various groups. For instance, the ESADDI for infants and children ≤ 10 years of age is 0.3–3 mg/day, and adolescent and adult ESADDI levels are 2–5 mg/day (National Research Council 1989). Intake of dietary Mn is under strong homeostatic control (Papavasiliou et al. 1966), and toxic­ ity associated with ingested Mn is rare; how­ ever, there have been reports of diminished intellectual function in children who have ingested drinking water with high Mn con­ centrations (Bouchard et al. 2007; Wasserman et al. 2006). When inhaled, Mn can bypass the biliary excretion mechanism and directly enter the sys­ temic circulation that results in neurotoxicity (Davis 1999; Keen et al. 1999). At high lev­ els of exposure, Mn can produce a neuro­ logic psychiatric disorder, manganism, which resembles Parkinsonian syndrome (Barceloux 1999; Lucchini et al. 2009), and has symp­ toms that can be clinically differentiated from Parkinson’s disease (Olanow 2004). These extrapyramidal and neuropsychiatric symptoms progress even after cessation of exposure (Pal et al. 1999). Adult studies have associated Mn exposure with deficits in neuropsychological and neuromotor function (Bowler et al. 2007; Mergler et al. 1999; Standridge et al. 2008) and increased risk of diagnosis of Parkinson’s disease (Finkelstein and Jerrett 2007; Lucchini et al. 2007). Low­level environmental expo ­ sure to Mn has been inversely associated with child cognition, behavior, and motor func­ tion (RiojasR­odríguez et al. 2010; Rodriguez­ Agudelo et al. 2006; Wright et al. 2006). Recently, the association between Mn exposure and adverse health outcomes among children has been identified as an inverted U­shaped curve. Henn et al. (2010) observed lower mental development scores among 12m­onth­ old children with both high and low blood concentrations of Mn, and Zota et al. (2009) reported lower infant birth weights among Environmental Health Perspectives • volume 119 | number 10 | October 2011 infants whose mothers had both low and high blood Mn concentration. Although a large­ scale epidemiologic study of Mn exposure on children was warranted from a scientific perspective, the academic research team recognized the importance of understanding the views of the stakeholders before conducting an epidemiologic research study (Goldberg­Freeman et al. 2007), par­ ticularly if the research focused on a pediat­ ric population in an Appalachian community. Although it is well documented that residents of rural areas are at risk for more health issues than are those living in urban areas (Hurley et al. 2000; Wewers et al. 2000), residents of Appalachia and other rural regions in the United States are some of the least researched populations (Elnick et al. 1995). Culturally, Appalachians are skeptical of outsiders and protect their personal privacy (Behringer et al. 2007), which is a potential barrier to researchers and others interested in improving the health of rural Americans. Residents of Appalachia and other rural regions in the United States have higher rates of poverty, lower education levels, and more limited access to health care (Friedell et al. 1998); compared with mortality rates of whites in the general U.S. population, Appalachian residents also have higher mortal­ ity rates for all causes of death (Halverson et al. 2004; Murray et al. 2005). Many Appalachian communities also bear an undue burden of environmental exposure to toxicants from coal mining (Hendryx and Ahern 2009), chemical industries (Steenland et al. 2009), metal refin­ eries (Haynes et al. 2010), and environmental tobacco smoke (Wewers et al. 2000). Thus, the academic research team from UC sought to engage an Appalachian­ American community in a bidirectional relationship built upon the CBPR principles before devel­ oping a research proposal. A bidirectional relationship is defined as the movement or sharing of information between the commu­ nity and the academic institution in a man­ ner that is mutually beneficial. In this review, we describe how UC partnered with NCA to identify the primary research question and the community’s thoughts and perceptions regarding local air quality, perceived effects on health, and its perception of risk informa­ tion sources. These partnershipb­uilding steps were essential for developing and conducting a large­scale epidemio logic research project and for gathering baseline information per­ tinent for designing community­appropriate risk communication messages. Materials and Methods Building an academic–community partner- ship. The partnership between NCA and UC environmental health researchers was initiated by a key relationship between the first author (E.N.H.) and the second author (C.B.). 1365