Making the invisible visible: Using a qualitative system dynamics model to map disparities in cumulative environmental stressors and children's neurodevelopment.

BACKGROUND: The combined effects of multiple environmental toxicants and social stressor exposures are widely recognized as important public health problems, likely contributing to health inequities. However, US policy makers at state and federal levels typically focus on one stressor exposure at a time and have failed to develop comprehensive strategies to reduce multiple co-occurring exposures, mitigate cumulative risks and prevent harm. This research aimed to move from considering disparate environmental stressors in isolation to mapping the links between environmental, economic, social and health outcomes as a dynamic complex system using children's exposure to neurodevelopmental toxicants as an illustrative example. Such a model can be used to support a broad range of child developmental and environmental health policy stakeholders in improving their understanding of cumulative effects of multiple chemical, physical, biological and social environmental stressors as a complex system through a collaborative learning process. METHODS: We used system dynamics (SD) group model building to develop a qualitative causal theory linking multiple interacting streams of social stressors and environmental neurotoxicants impacting children's neurodevelopment. A 2 1/2-day interactive system dynamics workshop involving experts across multiple disciplines was convened to develop the model followed by qualitative survey on system insights. RESULTS: The SD causal map covered seven interconnected themes: environmental exposures, social environment, health status, education, employment, housing and advocacy. Potential high leverage intervention points for reducing disparities in children's cumulative neurotoxicant exposures and effects were identified. Workshop participants developed deeper level of understanding about the complexity of cumulative environmental health risks, increased their agreement about underlying causes, and enhanced their capabilities for integrating diverse forms of knowledge about the complex multi-level problem of cumulative chemical and non-chemical exposures. CONCLUSION: Group model building using SD can lead to important insights to into the sociological, policy, and institutional mechanisms through which disparities in cumulative impacts are transmitted, resisted, and understood.

Both parents matter: a national-scale analysis of parental race/ethnicity, disparities in prenatal PM2.5 exposures and related impacts on birth outcomes.

BACKGROUND: Most U.S. studies that report racial/ethnic disparities in increased risk of low birth weight associated with air pollution exposures have been conducted in California or northeastern states and/or urban areas, limiting generalizability of study results. Few of these studies have examined maternal racial/ethnic groups other than Non-Hispanic Black, non-Hispanic White and Hispanic, nor have they included paternal race. We aimed to examine the independent effects of PM2.5 on birth weight among a nationally representative sample of U.S. singleton infants and how both maternal and paternal race/ethnicity modify relationships between prenatal PM2.5 exposures and birth outcomes. METHODS: We used data from the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B), a longitudinal nationally representative cohort of 10,700 U.S. children born in 2001, which we linked to U.S.EPA's Community Multi-scale Air Quality (CMAQ)-derived predicted daily PM2.5 concentrations at the centroid of each Census Bureau Zip Code Tabulation Area (ZCTA) for maternal residences. We examined relationships between term birthweight (TBW), term low birthweight rate (TLBW) and gestational PM2.5 pollutant using multivariate regression models. Effect modification of air pollution exposures on birth outcomes by maternal and paternal race was evaluated using stratified models. All analyses were conducted with sample weights to provide national-scale estimates. RESULTS: The majority of mothers were White (61%). Fourteen percent of mothers identified as Black, 21% as Hispanic, 3% Asian American and Pacific Islander (AAPI) and 1% American Indian and Alaskan Native (AIAN). Fathers were also racially/ethnically diverse with 55% identified as White Non-Hispanic, 10% as Black Non-Hispanic, 19% as Hispanic, 3% as AAPI and 1% as AIAN. Results from the chi-square and ANOVA tests of significance for racial/ethnic differences indicate disparities in prenatal exposures and birth outcomes by both maternal and paternal race/ethnicity. Prenatal PM2.5 was associated with reduced birthweights during second and third trimester and over the entire gestational period in adjusted regression models, although results did not reach statistical significance. In models stratified by maternal race and paternal race, one unit increase in PM2.5 was statistically significantly associated with lower birthweights among AAPI mothers, -5.6 g (95% CI:-10.3, -1.0 g) and AAPI fathers, -7.6 g (95% CI: -13.1, -2.1 g) during 3rd trimester and among births where father's race was not reported, -14.2 g (95% CI: -24.0, -4.4 g). CONCLUSIONS: These data suggest that paternal characteristics should be used, in addition to maternal characteristics, to describe the risks of adverse birth outcomes. Additionally, our study suggests that serious consideration should be given to investigating environmental and social mechanisms, such as air pollution exposures, as potential contributors to disparities in birth outcomes among AAPI populations.

Mixture toxicity, cumulative risk, and environmental justice in United States federal policy, 1980-2016 : Why, with much known, was little done?

Toxic chemicals - "toxicants" - have been studied and regulated as single entities, and, carcinogens aside, almost all toxicants, single or mixed and however altered, have been thought harmless in very low doses or very weak concentrations. Yet much work in recent decades has shown that toxicants can injure wildlife, laboratory animals, and humans following exposures previously expected to be harmless. Additional work has shown that toxicants can act not only individually and cumulatively but also collectively and even synergistically and that they affect disadvantaged communities inordinately - and therefore, as argued by reformers, unjustly. As late as December 2016, the last full month before the inauguration of a president promising to rescind major environmental regulations, the United States federal environmental-health establishment, as led by the Environmental Protection Agency (EPA), had not developed coherent strategies to mitigate such risks, to alert the public to their plausibility, or to advise leadership in government and industry about their implications. To understand why, we examined archival materials, reviewed online databases, read internal industry communications, and interviewed experts. We confirmed that external constraints, statutory and judicial, had been in place prior to EPA's earliest interest in mixture toxicity, but we found no overt effort, certainly no successful effort, to loosen those constraints. We also found internal constraints: concerns that fully committing to the study of complex mixtures involving numerous toxicants would lead to methodological drift within the toxicological community and that trying to act on insights from such study could lead only to regulatory futility. Interaction of these constraints, external and internal, shielded the EPA by circumscribing its responsibilities and by impeding movement toward paradigmatic adjustment, but it also perpetuated scientifically dubious policies, such as those limiting the evaluation of commercial chemical formulations, including pesticide formulations, to only those ingredients said by their manufacturers to be active. In this context, regulators' disregard of synergism contrasted irreconcilably with biocide manufacturers' understanding that synergism enhanced lethality and patentability. In the end, an effective national response to mixture toxicity, cumulative risk, and environmental injustice did not emerge. In parallel, though, the National Institute of Environmental Health Sciences, which was less constrained, pursued with scientific investigation what the EPA had not pursued with regulatory action.

Healthy Air, Healthy Brains: Advancing Air Pollution Policy to Protect Children's Health.

Evidence is growing on the adverse neurodevelopmental effects of exposure to combustion-related air pollution. Project TENDR (Targeting Environmental Neurodevelopmental Risks), a unique collaboration of leading scientists, health professionals, and children's and environmental health advocates, has identified combustion-related air pollutants as critical targets for action to protect healthy brain development. We present policy recommendations for maintaining and strengthening federal environmental health protections, advancing state and local actions, and supporting scientific research to inform effective strategies for reducing children's exposures to combustion-related air pollution. Such actions not only would improve children's neurological development but also would have the important co-benefit of climate change mitigation and further improvements in other health conditions.

Trends and disparities in urinary BPA concentrations among U.S. emerging adults.

BACKGROUND: Emerging adulthood (ages 18-25 years) is a key turning point in the life course characterized by particularly poor eating behaviors (e.g., low in fruits and vegetables, and high in fast food) and weight gain. Emerging adults are also prime consumers of personal care and other consumer products that may result in differential exposures to environmental contaminants, such as Bisphenol A (BPA), compared to adults aged 26+ years. This is of concern given BPA has been associated with adverse health outcomes such as obesity, metabolic disorders, miscarriage, infertility and breast cancer. However, no research has examined exposure to BPA among emerging adults. OBJECTIVE: To assess trends of exposure to urinary BPA among a representative sample of emerging adults compared to adults aged 26+ years. Secondarily, we aimed to identify differential associations between BPA concentrations and sociodemographic characteristics and BMI by age group. METHODS: This study uses National Health and Examination Surveys (NHANES) over 2003-2014 to test differences in BPA concentrations comparing emerging adults to adults aged 26+ years. Generalized linear models predicting log BPA by age group and sex, race/ethnicity, education, income, and food security status, and generalized linear models predicting BMI by log BPA, both age group and age as a continuous variable, sex, race/ethnicity, education, income, and food security status were conducted. Interactions with age group (i.e., age group x sex) were examined for the mutually adjusted models. All models controlled for survey year, month, and time of day, and were run with, and without, an adjustment for urinary creatinine. RESULTS: In models adjusted, and not adjusted, for urinary creatinine, emerging adults had a higher log BPA concentration than adults aged 26+ years (ß=0.153, p=0.004; ß=0.544, p<0.001), and a significantly steeper decline in BPA concentration between 2003-2004 and 2013-2014 than adults aged 26+ years (ß=-0.051, p=0.002; ß=-0.071, p=0.001). Males' log BPA concentration were lower than that for females when urinary creatinine was included in the model, and higher when urinary creatinine was excluded from the model (ß=-0.188, p<0.001; ß=0.203, p<0.001). Higher income was significantly associated with lower log BPA concentration (ß=-0.220, p<0.001; ß=-0.166, p<0.001). A significant interaction between emerging adult age group and food security status was observed, which was associated with higher BPA exposures. Log BPA concentration was associated with BMI only when urinary creatinine was excluded from the models (urinary creatinine included: ß=0.031, p=0.747; ß=0.022, p=0.815, urinary creatinine excluded: ß=0.528, p<0.001; ß=0.552, p<0.001). CONCLUSION: Findings indicate that emerging adults had higher BPA exposures than adults aged 26+ years in 2003-2004, and that emerging adults' exposure level has decreased faster than that of adults aged 26+ years. There were suggestions that the BPA concentration of emerging adults in 2013-2014 was lower than that for adults aged 26+ years, and that BPA exposure is associated with higher BMI. Our results highlight the need for additional research to identify the sources and routes of exposure to BPA and BPA replacements among emerging adults and to better characterize the variability in exposure. Intervention studies are needed to assist emerging adults in limiting their exposure to BPA, and potentially also the BPA alternatives.

Trends in neonicotinoid pesticide residues in food and water in the United States, 1999-2015.

BACKGROUND: Neonicotinoids are a class of systemic insecticides widely used on food crops globally. These pesticides may be found in "off-target" food items and persist in the environment. Despite the potential for extensive human exposure, there are limited studies regarding the prevalence of neonicotinoid residues in foods sold and consumed in the United States. METHODS: Residue data for seven neonicotinoid pesticides collected between 1999 and 2015 by the US Department of Agriculture's Pesticide Data Program (PDP) were collated and summarized by year across various food commodities, including fruit, vegetable, meat, dairy, grain, honey, and baby food, as well as water to qualitatively describe and examine trends in contamination frequency and residue concentrations. RESULTS: The highest detection frequencies (DFs) for neonicotinoids by year on all commodities were generally below 20%. Average DFs over the entire study period, 1999-2015, for domestic and imported commodities were similar at 4.5%. For all the samples (both domestic and imported) imidacloprid was the neonicotinoid with the highest overall detection frequency at 12.0%. However, higher DFs were observed for specific food commodity-neonicotinoid combinations such as: cherries (45.9%), apples (29.5%), pears (24.1%) and strawberries (21.3%) for acetamiprid; and cauliflower (57.5%), celery (20.9%), cherries (26.3%), cilantro (30.6%), grapes (28.9%), collard greens (24.9%), kale (31.4%), lettuce (45.6%), potatoes (31.2%) and spinach (38.7%) for imidacloprid. Neonicotinoids were also detected in organic commodities, (DF < 6%). Individual commodities with at least 5% of samples testing positive for two or more neonicotinoids included apples, celery, and cherries. Generally, neonicotinoid residues on food commodities did not exceed US Environmental Protection Agency tolerance levels. Increases in detection trends for both finished and untreated water samples for imidacloprid were observed from 2004 to 2011. CONCLUSIONS: Analysis of PDP data indicates that low levels of neonicotinoids are present in commonly-consumed fruits and vegetables sold in the US. Trends in detection frequencies suggest an increase in use of acetamiprid, clothianidin and thiamethoxam as replacements for imidacloprid. Given these findings, more extensive surveillance of the food and water supply is warranted, as well as biomonitoring studies and assessment of cumulative daily intake in high risk groups, including pregnant women and infants.

Income Inequality and US Children's Secondhand Smoke Exposure: Distinct Associations by Race-Ethnicity.

INTRODUCTION: Prior studies have found considerable racial and ethnic disparities in secondhand smoke (SHS) exposure. Although a number of individual-level determinants of this disparity have been identified, contextual determinants of racial and ethnic disparities in SHS exposure remain unexamined. The objective of this study was to examine disparities in serum cotinine in relation to area-level income inequality among 14 649 children from the National Health and Nutrition Examination Survey. METHODS: We fit log-normal regression models to examine disparities in serum cotinine in relation to Metropolitan Statistical Areas level income inequality among 14 649 nonsmoking children aged 3-15 from the National Health and Nutrition Examination Survey (1999-2012). RESULT: Non-Hispanic black children had significantly lower serum cotinine than non-Hispanic white children (-0.26; 95% CI: -0.38, -0.15) in low income inequality areas, but this difference was attenuated in areas with high income inequality (0.01; 95% CI: -0.16, 0.18). Serum cotinine declined for non-Hispanic white and Mexican American children with increasing income inequality. Serum cotinine did not change as a function of the level of income inequality among non-Hispanic black children. CONCLUSIONS: We have found evidence of differential associations between SHS exposure and income inequality by race and ethnicity. Further examination of environments which engender SHS exposure among children across various racial/ethnic subgroups can foster a better understanding of how area-level income inequality relates to health outcomes such as levels of SHS exposure and how those associations differ by race/ethnicity. IMPLICATIONS: In the United States, the association between children's risk of SHS exposure and income inequality is modified by race/ethnicity in a manner that is inconsistent with theories of income inequality. In overall analysis this association appears to be as predicted by theory. However, race-specific analyses reveal that higher levels of income inequality are associated with lower levels of SHS exposure among white children, while levels of SHS exposure among non-Hispanic black children are largely invariant to area-level income inequality. Future examination of the link between income inequality and smoking-related health outcomes should consider differential associations across racial and ethnic subpopulations.

Effects of Behavioral, Clinical, and Policy Interventions in Reducing Human Exposure to Bisphenols and Phthalates: A Scoping Review.

BACKGROUND: There is growing interest in evidence-based interventions, programs, and policies to mitigate exposures to bisphenols and phthalates and in using implementation science frameworks to evaluate hypotheses regarding the importance of specific approaches to individual or household behavior change or institutions adopting interventions. OBJECTIVES: This scoping review aimed to identify, categorize, and summarize the effects of behavioral, clinical, and policy interventions focused on exposure to the most widely used and studied bisphenols [bisphenol A (BPA), bisphenol S (BPS), and bisphenol F (BPF)] and phthalates with an implementation science lens. METHODS: A comprehensive search of all individual behavior, clinical, and policy interventions to reduce exposure to bisphenols and phthalates was conducted using PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Google Scholar. We included studies published between January 2000 and November 2022. Two reviewers screened references in CADIMA, then extracted data (population characteristics, intervention design, chemicals assessed, and outcomes) for studies meeting inclusion criteria for the present review. RESULTS: A total of 58 interventions met the inclusion criteria. We classified interventions as dietary (n=27), clinical (n=13), policy (n=14), and those falling outside of these three categories as "other" (n=4). Most interventions (81%, 47/58) demonstrated a decrease in exposure to bisphenols and/or phthalates, with policy level interventions having the largest magnitude of effect. DISCUSSION: Studies evaluating policy interventions that targeted the reduction of phthalates and BPA in goods and packaging showed widespread, long-term impact on decreasing exposure to bisphenols and phthalates. Clinical interventions removing bisphenol and phthalate materials from medical devices and equipment showed overall reductions in exposure biomarkers. Dietary interventions tended to lower exposure with the greatest magnitude of effect in trials where fresh foods were provided to participants. The lower exposure reductions observed in pragmatic nutrition education trials and the lack of diversity (sociodemographic backgrounds) present limitations for generalizability to all populations. https://doi.org/10.1289/EHP11760.

Disparities in Toxic Chemical Exposures and Associated Neurodevelopmental Outcomes: A Scoping Review and Systematic Evidence Map of the Epidemiological Literature.

BACKGROUND: Children are routinely exposed to chemicals known or suspected of harming brain development. Targeting Environmental Neuro-Development Risks (Project TENDR), an alliance of >50 leading scientists, health professionals, and advocates, is working to protect children from these toxic chemicals and pollutants, especially the disproportionate exposures experienced by children from families with low incomes and families of color. OBJECTIVE: This scoping review was initiated to map existing literature on disparities in neurodevelopmental outcomes for U.S. children from population groups who have been historically economically/socially marginalized and exposed to seven exemplar neurotoxicants: combustion-related air pollution (AP), lead (Pb), mercury (Hg), organophosphate pesticides (OPs), phthalates (Phth), polybrominated diphenyl ethers (PBDEs), and polychlorinated biphenyls (PCBs). METHODS: Systematic literature searches for the seven exemplar chemicals, informed by the Population, Exposure, Comparator, Outcome (PECO) framework, were conducted through 18 November 2022, using PubMed, CINAHL Plus (EBSCO), GreenFILE (EBSCO), and Web of Science sources. We examined these studies regarding authors' conceptualization and operationalization of race, ethnicity, and other indicators of sociodemographic and socioeconomic disadvantage; whether studies presented data on exposure and outcome disparities and the patterns of those disparities; and the evidence of effect modification by or interaction with race and ethnicity. RESULTS: Two hundred twelve individual studies met the search criteria and were reviewed, resulting in 218 studies or investigations being included in this review. AP and Pb were the most commonly studied exposures. The most frequently identified neurodevelopmental outcomes were cognitive and behavioral/psychological. Approximately a third (74 studies) reported investigations of interactions or effect modification with 69% (51 of 74 studies) reporting the presence of interactions or effect modification. However, less than half of the studies presented data on disparities in the outcome or the exposure, and fewer conducted formal tests of heterogeneity. Ninety-two percent of the 165 articles that examined race and ethnicity did not provide an explanation of their constructs for these variables, creating an incomplete picture. DISCUSSION: As a whole, the studies we reviewed indicated a complex story about how racial and ethnic minority and low-income children may be disproportionately harmed by exposures to neurotoxicants, and this has implications for targeting interventions, policy change, and other necessary investments to eliminate these health disparities. We provide recommendations on improving environmental epidemiological studies on environmental health disparities. To achieve environmental justice and health equity, we recommend concomitant strategies to eradicate both neurotoxic chemical exposures and systems that perpetuate social inequities. https://doi.org/10.1289/EHP11750.

Framing Environmental Health Decision-Making: The Struggle over Cumulative Impacts Policy.

Little progress has been made to advance U.S. federal policy responses to growing scientific findings about cumulative environmental health impacts and risks, which also show that many low income and racial and ethnic minority populations bear a disproportionate share of multiple environmental burdens. Recent scholarship points to a "standard narrative" by which policy makers rationalize their slow efforts on environmental justice because of perceived lack of data and analytical tools. Using a social constructivist approach, ethnographic research methods, and content analysis, we examined the social context of policy challenges related to cumulative risks and impacts in the state of Maryland between 2014 and 2016. We identified three frames about cumulative impacts as a health issue through which conflicts over such policy reforms materialize and are sustained: (a) perceptions of evidence, (b) interpretations of social justice, and (c) expectations of authoritative bodies. Our findings illustrate that policy impasse over cumulative impacts is highly dependent on how policy-relevant actors come to frame issues around legislating cumulative impacts, rather than the "standard narrative" of external constraints. Frame analysis may provide us with more robust understandings of policy processes to address cumulative risks and impacts and the social forces that create health policy change.

Confronting Racism in Environmental Health Sciences: Moving the Science Forward for Eliminating Racial Inequities.

BACKGROUND: The twin pandemics of COVID-19 and systemic racism during 2020 have forced a conversation across many segments of our society, including the environmental health sciences (EHS) research community. We have seen the proliferation of statements of solidarity with the Black Lives Matter movement and commitments to fight racism and health inequities from academia, nonprofit organizations, governmental agencies, and private corporations. Actions must now arise from these promises. As public health and EHS scientists, we must examine the systems that produce and perpetuate inequities in exposure to environmental pollutants and associated health effects. OBJECTIVES: We outline five recommendations the EHS research community can implement to confront racism and move our science forward for eliminating racial inequities in environmental health. DISCUSSION: Race is best considered a political label that promotes inequality. Thus, we should be wary of equating race with biology. Further, EHS researchers should seriously consider racism as a plausible explanation of racial disparities in health and consider structural racism as a factor in environmental health risk/impact assessments, as well as multiple explanations for racial differences in environmental exposures and health outcomes. Last, the EHS research community should develop metrics to measure racism and a set of guidelines on the use and interpretation of race and ethnicity within the environmental sciences. Numerous guidelines exist in other disciplines that can serve as models. By taking action on each of these recommendations, we can make significant progress toward eliminating racial disparities. https://doi.org/10.1289/EHP8186.

Dietary quality and bisphenols: trends in bisphenol A, F, and S exposure in relation to the Healthy Eating Index using representative data from the NHANES 2007-2016.

BACKGROUND: Given policy regulations restricting bisphenol A (BPA) in food-related products, and consumer concerns about adverse health effects, newer bisphenols such as bisphenol F (BPF) and bisphenol S (BPS) have been developed. Exposure to BPA has been linked to dietary behaviors and poor health outcomes. OBJECTIVES: We sought to examine how the Healthy Eating Index (HEI) and its 13 subgroups, the healthy American diet, the Mediterranean diet, the vegetarian diet, and other dietary quality behaviors are related to BPA and the newer substitutes in a representative sample of US adults. METHODS: Dietary intakes from the NHANES were used to determine dietary scores. Osmolality-adjusted urinary BPA (n = 6418) and BPF and BPS (n = 2520) concentrations were tested for their association with dietary intake in models that adjusted for sociodemographics. RESULTS: Compared with low scores, high scores for total HEI and the American, Mediterranean, and vegetarian diets were associated with lower odds of high BPA concentration (OR: 0.65, 0.60, 0.59, and 0.60, respectively). Of the HEI subgroups, lower BPA concentration was associated with high total fruit (OR: 0.61; 99.95% CI: 0.42, 0.89), whole fruit (OR: 0.59; 99.95% CI: 0.41, 0.86), and whole grain (OR: 0.68; 99.95% CI: 0.40, 0.94) intake, when compared with low intakes. Compared with low intakes, high intakes of plain and tap water were associated with lower odds of high BPA concentration (OR: 0.65; 99.95% CI: 0.47, 0.91 and OR: 0.70; 99.95% CI: 0.50, 0.99, respectively). A perception of high, compared with low, dietary quality was also associated with lower odds of high BPA concentration (OR: 0.72; 99.95% CI: 0.53, 0.98). CONCLUSIONS: Healthier dietary quality and several HEI subgroups were related to lower urinary BPA concentrations; no significant (P ≤ 0.0005) findings were observed for BPF and BPS. The association between bisphenol substitutes and dietary quality should continue to be monitored as bisphenol substitutes continue to increase in the food system.

Defining and Intervening on Cumulative Environmental Neurodevelopmental Risks: Introducing a Complex Systems Approach.

BACKGROUND: The combined effects of multiple environmental toxicants and social stressor exposures are widely recognized as important public health problems contributing to health inequities. However cumulative environmental health risks and impacts have received little attention from U.S. policy makers at state and federal levels to develop comprehensive strategies to reduce these exposures, mitigate cumulative risks, and prevent harm. An area for which the inherent limitations of current approaches to cumulative environmental health risks are well illustrated is children's neurodevelopment, which exhibits dynamic complexity of multiple interdependent and causally linked factors and intergenerational effects. OBJECTIVES: We delineate how a complex systems approach, specifically system dynamics, can address shortcomings in environmental health risk assessment regarding exposures to multiple chemical and nonchemical stressors and reshape associated public policies. DISCUSSION: Systems modeling assists in the goal of solving problems by improving the "mental models" we use to make decisions, including regulatory and policy decisions. In the context of disparities in children's cumulative exposure to neurodevelopmental stressors, we describe potential policy insights about the structure and behavior of the system and the types of system dynamics modeling that would be appropriate, from visual depiction (i.e., informal maps) to formal quantitative simulation models. A systems dynamics framework provides not only a language but also a set of methodological tools that can more easily operationalize existing multidisciplinary scientific evidence and conceptual frameworks on cumulative risks. Thus, we can arrive at more accurate diagnostic tools for children's' environmental health inequities that take into consideration the broader social and economic environment in which children live, grow, play, and learn. https://doi.org/10.1289/EHP7333.

Student Hunger on Campus: Food Insecurity Among College Students and Implications for Academic Institutions.

PURPOSE: To estimate the prevalence of food insecurity among students at a large mid-Atlantic publicly funded university; examine the association between food insecurity, demographic characteristics, potential financial risk factors, and self-reported physical and mental health and academic performance; and identify possible risk factors for food insecurity. DESIGN: Cross-sectional survey. SETTING: Large, public mid-Atlantic university. PARTICIPANTS: Two hundred thirty-seven undergraduate students. MEASURES: US Department of Agriculture (USDA) 18-item Household Food Security Survey Module (HFSSM) and questions on demographics, student status, economic factors, housing stability, living arrangements, academic performance, and self-rated physical health and depression symptoms. ANALYSIS: Multivariate logistic regression analysis. RESULTS: Among students surveyed, 15% were food insecure; an additional 16% were at risk of food insecurity. Students who were African American, other race/ethnicity, receiving multiple forms of financial aid, or experiencing housing problems were more likely to be food insecure or at the risk of food insecurity (Adjusted Odds Ratio [AOR] = 4.00, 95% confidence interval [CI] = 1.83-8.71, P value < .0001; AOR = 5.26, 95% CI = 1.85-14.98, P value = .002; AOR = 3.43, 95% CI = 1.85-6.37, P value <.001; AOR = 8.00, 95% CI = 3.57-17.93, P value < .0001, respectively). Food secure students were less likely to report depression symptoms than at-risk or food insecure students. CONCLUSION: Food insecurity among college students is an important public health concern that might have implications for academic performance, retention, and graduation rates. Universities that measure food insecurity among their students will be better positioned to advocate for policy changes at state and federal levels regarding college affordability and student financial assistance.

Methods for Evaluating the Combined Effects of Chemical and Nonchemical Exposures for Cumulative Environmental Health Risk Assessment.

Cumulative risk assessment (CRA) has been proposed as a means of evaluating possible additive and synergistic effects of multiple chemical, physical and social stressors on human health, with the goal of informing policy and decision-making, and protecting public health. Routine application of CRA to environmental regulatory and policy decision making, however, has been limited due to a perceived lack of appropriate quantitative approaches for assessing combined effects of chemical and nonchemical exposures. Seven research projects, which represented a variety of disciplines, including population health science, laboratory science, social sciences, geography, statistics and mathematics, were funded by the US Environmental Protection Agency (EPA) to help address this knowledge gap. We synthesize key insights from these unique studies to determine the implications for CRA practice and priorities for further research. Our analyses of these seven projects demonstrate that the necessary analytical methods to support CRA are available but are ultimately context-dependent. These projects collectively provided advancements for CRA in the areas of community engagement, characterization of exposures to nonchemical stressors, and assessment of health effects associated with joint exposures to chemical and psychosocial stressors.

Hazard Ranking Methodology for Assessing Health Impacts of Unconventional Natural Gas Development and Production: The Maryland Case Study.

The recent growth of unconventional natural gas development and production (UNGDP) has outpaced research on the potential health impacts associated with the process. The Maryland Marcellus Shale Public Health Study was conducted to inform the Maryland Marcellus Shale Safe Drilling Initiative Advisory Commission, State legislators and the Governor about potential public health impacts associated with UNGDP so they could make an informed decision that considers the health and well-being of Marylanders. In this paper, we describe an impact assessment and hazard ranking methodology we used to assess the potential public health impacts for eight hazards associated with the UNGDP process. The hazard ranking included seven metrics: 1) presence of vulnerable populations (e.g. children under the age of 5, individuals over the age of 65, surface owners), 2) duration of exposure, 3) frequency of exposure, 4) likelihood of health effects, 5) magnitude/severity of health effects, 6) geographic extent, and 7) effectiveness of setbacks. Overall public health concern was determined by a color-coded ranking system (low, moderately high, and high) that was generated based on the overall sum of the scores for each hazard. We provide three illustrative examples of applying our methodology for air quality and health care infrastructure which were ranked as high concern and for water quality which was ranked moderately high concern. The hazard ranking was a valuable tool that allowed us to systematically evaluate each of the hazards and provide recommendations to minimize the hazards.

Place-based perceptions of the impacts of fracking along the Marcellus Shale.

We examined community perspectives and experiences with fracking in Doddridge County, West Virginia, USA as part of a larger assessment to investigate the potential health impacts associated with fracking in neighboring Maryland, USA. In November 2013, we held two focus groups with community residents who had been impacted by fracking operations and conducted field observations in the impacted areas. Employing grounded theory, we conducted qualitative analysis to explore emergent themes related to direct and indirect health impacts of fracking. Three components of experience were identified, including (a) meanings of place and identity, (b) transforming relationships, and (c) perceptions of environmental and health impacts. Our findings indicate that fracking contributes to a disruption in residents' sense of place and social identity, generating widespread social stress. Although community residents acknowledged the potential for economic growth brought about by fracking, rapid transformations in meanings of place and social identity influenced residents' perceptions of environmental and health impacts. Our findings suggest that in order to have a more complete understanding of the health impacts of fracking, future work must consider the complex linkages between social disruption, environmental impacts, and health outcomes through critical engagements with communities undergoing energy development.

Engaging Communities in Research on Cumulative Risk and Social Stress-Environment Interactions: Lessons Learned from EPA's STAR Program.

Studies have documented cumulative health effects of chemical and nonchemical exposures, particularly chronic environmental and social stressors. Environmental justice groups have advocated for community participation in research that assesses how these interactions contribute to health disparities experienced by low-income and communities of color. In 2009, the U.S. Environmental Protection Agency issued a request for research applications (RFA), "Understanding the Role of Nonchemical Stressors and Developing Analytic Methods for Cumulative Risk Assessments." Seven research projects were funded to help address this knowledge gap. Each engaged with communities in different ways. We describe the community engagement approaches of the seven research projects, which ranged from outreach through shared leadership/participatory. We then assess the experiences of these programs with respect to the community engagement goals of the RFA. We present insights from these community engagement efforts, including how the grants helped to build or enhance the capacity of community organizations in addition to contributing to the research projects. Our analysis of project proposals, annual grantee reports, and participant observation of these seven projects suggests guidelines for the development of future funding mechanisms and for conducting community-engaged research on cumulative risk involving environmental and social stressors including: 1) providing for flexibility in the mode of community engagement; 2) addressing conflict between research timing and engagement needs, 3) developing approaches for communicating about the uniquely sensitive issues of nonchemical stressors and social risks; and 4) encouraging the evaluation of community engagement efforts.

Environmental health disparities: a framework integrating psychosocial and environmental concepts.

Although it is often acknowledged that social and environmental factors interact to produce racial and ethnic environmental health disparities, it is still unclear how this occurs. Despite continued controversy, the environmental justice movement has provided some insight by suggesting that disadvantaged communities face greater likelihood of exposure to ambient hazards. The exposure-disease paradigm has long suggested that differential "vulnerability" may modify the effects of toxicants on biological systems. However, relatively little work has been done to specify whether racial and ethnic minorities may have greater vulnerability than do majority populations and, further, what these vulnerabilities may be. We suggest that psychosocial stress may be the vulnerability factor that links social conditions with environmental hazards. Psychosocial stress can lead to acute and chronic changes in the functioning of body systems (e.g., immune) and also lead directly to illness. In this article we present a multidisciplinary framework integrating these ideas. We also argue that residential segregation leads to differential experiences of community stress, exposure to pollutants, and access to community resources. When not counterbalanced by resources, stressors may lead to heightened vulnerability to environmental hazards.