The CHANGE (Climate Health ANalysis Grading Evaluation) tool for weight of evidence reviews on climate change and health research.

BACKGROUND: Climate change has been identified as one of the biggest threats to human health. Despite this claim, there are no standardized tools that assess the rigor of published literature for use in weight of evidence (WOE) reviews. Standardized assessment tools are essential for creating clear and comparable WOE reviews. As such, we developed a standardized tool for evaluating the quality of climate change and health studies focused on evaluating studies that quantify exposure-response relationships and studies that implement and/or evaluate adaptation interventions. METHODS: The authors explored systematic-review methodology to enhance transparency and increase efficiency in summarizing and synthesizing findings from studies on climate change and health research. The authors adapted and extended existing WOE methods to develop the CHANGE (Climate Health ANalysis Grading Evaluation) tool. The resulting assessment tool has been refined through application and subsequent team input. RESULTS: The CHANGE tool is a two-step standardized tool for systematic review of climate change and health studies of exposure-response relationships and adaptation intervention studies. Step one of the CHANGE tool aims to classify studies included in weight-of-evidence reviews and step two assesses the quality and presence of bias in the climate change and health studies. CONCLUSION: The application of the CHANGE tool in WOE reviews of climate change and health will lead to increased comparability, objectivity, and transparency within this research area.

Long-term association of air pollution and incidence of lung cancer among older Americans: A national study in the Medicare cohort.

BACKGROUND: Despite strong evidence of the association of fine particulate matter (PM2.5) exposure with an increased risk of lung cancer mortality, few studies had investigated associations of multiple pollutants simultaneously, or with incidence, or using causal methods. Disparities were also understudied. OBJECTIVES: We investigated long-term effects of PM2.5, nitrogen dioxide (NO2), warm-season ozone, and particle radioactivity (PR) exposures on lung cancer incidence in a nationwide cohort. METHODS: We conducted a cohort study with Medicare beneficiaries (aged ≥ 65 years) continuously enrolled in the fee-for-service program in the contiguous US from 2001 to 2016. Air pollution exposure was averaged across three years and assigned based on ZIP code of residence. We fitted Cox proportional hazards models to estimate the hazard ratio (HR) for lung cancer incidence, adjusted for individual- and neighborhood-level confounders. As a sensitivity analysis, we evaluated the causal relationships using inverse probability weights. We further assessed effect modifications by individual- and neighborhood-level covariates. RESULTS: We identified 166,860 lung cancer cases of 12,429,951 studied beneficiaries. In the multi-pollutant model, PM2.5 and NO2 exposures were statistically significantly associated with increased lung cancer incidence, while PR was marginally significantly associated. Specifically, the HR was 1.008 (95% confidence interval [CI]: 1.005, 1.011) per 1-µg/m3 increase in PM2.5, 1.013 (95% CI: 1.012, 1.013) per 1-ppb increase in NO2, and 1.005 (0.999, 1.012) per 1-mBq/m3 increase in PR. At low exposure levels, all pollutants were associated with increased lung cancer incidence. Men, older individuals, Blacks, and residents of low-income neighborhoods experienced larger effects of PM2.5 and PR. DISCUSSION: Long-term PM2.5, NO2, and PR exposures were independently associated with increased lung cancer incidence among the national elderly population. Low-exposure analysis indicated that current national standards for PM2.5 and NO2 were not restrictive enough to protect public health, underscoring the need for more stringent air quality regulations.

Environmental health perceptions of urban youth from low-income communities: A qualitative photovoice study and framework.

BACKGROUND: Children are amongst the most susceptible groups to environmental exposures, for both immediate and life-course health outcomes. Despite their increased susceptibility, children's knowledge, experiences and voices are understudied. A deeper understanding of children's environmental health perceptions has the potential to better inform policy, develop targeted interventions and improve public health outcomes. METHODS: In this study, our community-academic partnership used the Photovoice research method to examine how urban children from low-income communities perceive environmental influences on their health. Twenty children, ages 10-12, took photographs and participated in focus group interviews regarding their perspectives on how the environment influences their health. RESULTS: Qualitative analyses revealed five major thematic categories: environmental exposures, environmental health sentiments, environmental health outcomes, interest in environmental health and environmental health solutions. We used the findings to develop an environmental health perspective theoretical framework that can inform future work designed to promote the environmental health and well-being of children from low-income communities in urban communities. CONCLUSION: Photovoice enabled children from low-income communities to capture and communicate their environmental health perceptions. These findings have the potential to inform and identify potential targets and opportunities for environmental health interventions and promotion in their communities. PATIENT OR PUBLIC CONTRIBUTION: Partnerships with community-based organizations were central to the present study. By design, these community-based partners were involved in the conduct and procedures of the study.

Disparities in survival improvement for U.S. childhood and adolescent cancer between 1995 and 2019: An analysis of population-based data.

BACKGROUND: Although treatment advances have increased childhood and adolescent cancer survival, whether patient subgroups have benefited equally from these improvements is unclear. METHODS: Data on 42,865 malignant primary cancers diagnosed between 1995 and 2019 in individuals ≤ 19 years were obtained from 12 Surveillance, Epidemiology, and End Results registries. Hazard ratios (HRs) and 95 % confidence intervals (CIs) for cancer-specific mortality by age group (0-14 and 15-19 years), sex, and race/ethnicity were estimated using flexible parametric models with a restricted cubic spline function in each of the periods: 2000-2004, 2005-2009, 2010-2014 and 2015-2019, versus 1995-1999. Interactions between diagnosis period and age group (children 0-14 and adolescents 15-19 years at diagnosis), sex, and race/ethnicity were assessed using likelihood ratio tests. Five-year cancer-specific survival rates for each diagnosis period were further predicted. RESULTS: Compared with the 1995-1999 cohort, the risk of dying from all cancers combined decreased in subgroups defined by age, sex and race/ethnicity with HRs ranging from 0.50 to 0.68 for the 2015-2019 comparison. HRs were more variable by cancer subtype. There were no statistically significant interactions by age group (Pinteraction=0.05) or sex (Pinteraction=0.71). Despite non-significant differences in cancer-specific survival improvement across different races and ethnicities (Pinteraction=0.33) over the study period, minorities consistently experienced inferior survival compared with non-Hispanic Whites. CONCLUSIONS: The substantial improvements in cancer-specific survival for childhood and adolescent cancer did not differ significantly by different age, sex, and race/ethnicity groups. However, persistent gaps in survival between minorities and non-Hispanic Whites are noteworthy.

Health Insurance Coverage and Racial/Ethnic Disparities in US Childhood and Adolescent Cancer Survival.

OBJECTIVE: To evaluate potential effect modification by health insurance coverage on racial and ethnic disparities in cancer survival among US children and adolescents. STUDY DESIGN: Data from 54 558 individuals diagnosed with cancer at ≤ 19 years between 2004 and 2010 were obtained from the National Cancer Database. Cox proportional hazards regression was used for analyses. An interaction term between race/ethnicity and health insurance type was included to examine racial/ethnic disparities in survival by each insurance status category. RESULTS: Racial/ethnic minorities experienced a 14%-42% higher hazard of death compared with non-Hispanic Whites (NHWs) with magnitudes varying by health insurance type (Pinteraction < .001). Specifically, among those reported as privately insured, the hazard of death was higher for non-Hispanic Blacks (NHBs) (hazard ratio [HR] = 1.48, 95% CI: 1.36-1.62), non-Hispanic American Indian/Alaskan Natives (HR = 1.99, 95% CI: 1.36-2.90), non-Hispanic Asians or Pacific Islanders (HR = 1.30, 95% CI: 1.13-1.50), and Hispanics (HR = 1.28, 95% CI: 1.17-1.40) vs NHWs. Racial/ethnic disparities in survival among those reported as covered by Medicaid were present for NHBs (HR = 1.30, 95% CI: 1.19-1.43) but no other racial/ethnic minorities (HR ranges: 0.98∼1.00) vs NHWs. In the uninsured group, the hazard of death for NHBs (HR = 1.68, 95% CI: 1.26-2.23) and Hispanics (HR = 1.27, 95% CI: 1.01-1.61) was higher vs NHWs. CONCLUSIONS: Disparities in survival exist across insurance types, particularly for NHB childhood and adolescent cancer patients vs NHWs with private insurance. These findings provide insights for research and policy, and point to the need for more efforts on promoting health equity while improving health insurance coverage.

The impact of health insurance coverage on racial/ethnic disparities in US childhood and adolescent cancer stage at diagnosis.

BACKGROUND: Racial/ethnic minority children and adolescents are more likely to have an advanced cancer diagnosis compared with non-Hispanic Whites, which may relate to the lack of consistent health care access. This study aims to describe racial/ethnic disparities in cancer diagnosis stage among children and adolescents and assess whether health insurance mediates these disparities. METHODS: Data on individuals ≤19 years of age diagnosed with primary cancers from 2007 to 2016 were obtained from the Surveillance, Epidemiology, and End Results 18 database. Prevalence ratios (PRs) and 95% confidence intervals (CIs) for the association between race/ethnicity and cancer diagnosis stage were calculated using Poisson regression. Analyses addressing health insurance as a potential mediator were also performed. RESULTS: Compared with non-Hispanic Whites, racial/ethnic minorities had a higher prevalence of a distant cancer diagnosis, with PRs of 1.31 (95% CI, 1.23-1.40) for non-Hispanic Blacks, 1.14 (95% CI, 1.04-1.24) for non-Hispanic Asian/Pacific Islanders, and 1.15 (95% CI, 1.09-1.21) for Hispanics. These associations were attenuated when adjusting for health insurance, with PRs of 1.24 (95% CI, 1.16-1.33) for non-Hispanic Blacks, 1.11 (95% CI, 1.02-1.21) for non-Hispanic Asian/Pacific Islanders, and 1.07 (95% CI, 1.01-1.13) for Hispanics. Any Medicaid or no insurance at diagnosis mediated 49%, 22%, and 9% of the observed association with distant stage in Hispanics, non-Hispanic Blacks, and non-Hispanic Asian/Pacific Islanders, respectively. CONCLUSIONS: Disparities in cancer diagnosis stage in racial/ethnic minority children and adolescents may be partially explained by health insurance coverage. Further research is needed to understand the mechanisms.

Multimorbidity and Employment Outcomes Among Middle-Aged US Cancer Survivors.

OBJECTIVE: The objective of this study was to evaluate the relationship between multimorbidity and subsequent 2-year employment outcomes among middle-aged United States (US) cancer survivors. In addition, we examined whether the relationship differed by survivor characteristics. METHODS: Data of 633 cancer survivors (ages 51 to 64) from the 2014 Health and Retirement Study were used to identify multimorbidity profiles and evaluate associations between multimorbidity and prolonged unemployment during follow-up. RESULTS: Approximately 64% of cancer survivors met the criteria for multimorbidity. Latent class analysis revealed three distinct multimorbidity profiles distinguished by the presence or absence of psychiatric disorders. We observed a significant association between high psychiatric multimorbidity and prolonged unemployment after 2-year follow-up (relative risk = 2.78, 95% Confidence Interval = 1.28 to 6.00), with the effect more pronounced among low-income survivors. CONCLUSIONS: Psychiatric multimorbidity was associated with prolonged unemployment among middle-aged cancer survivors, particularly among low-income survivors.

The COVID-19 Pandemic as a Threat Multiplier for Childhood Health Disparities: Evidence from St. Louis, MO.

The COVID-19 pandemic has highlighted socioeconomic and racial health disparities in the USA. In this study, we examined the COVID-19 pandemic as a threat multiplier for childhood health disparities by evaluating health behavior changes among urban St. Louis, MO, children (ages 6-14) during the COVID-19 pandemic. From 27 October to 10 December 2020, 122 parents/guardians reported on their children's health behaviors (Eating, Sleeping, Physical activity, Time outside, Time with friends in-person, Time with friends remotely, Time using media for educational proposes, Time using media for non-educational proposes, and Social connectedness) prior to and during the COVID-19 pandemic. We ran K-means cluster analyses to identify distinct health behavior cluster profiles. Relative risks were determined to evaluate behavioral differences between the two clusters. Two distinct cluster profiles were identified: a High Impact profile (n = 49) and a Moderate Impact profile (n = 73). Children in the High Impact cluster had a greater risk of being diagnosed with COVID-19, developed worsened eating habits (RR = 2.10; 95% CI = 1.50-2.93), spent less time sleeping, and spent less time outdoors (RR = 1.55; 95% CI = 1.03-2.43) than the Moderate Impact cluster. The High Impact cluster was more likely to include Black children and children from single-adult households than the Moderate Impact cluster (both p < 0.05). Our findings suggest that the COVID-19 pandemic may be a threat multiplier for childhood health disparities. Further research is needed to better understand the long-term effects of the COVID-19 pandemic on children's health.

The impact of nature-based education on health-related quality of life among low-income youth: results from an intervention study.

BACKGROUND: Nature experiences have been shown to promote physical, emotional, mental and overall health. However, low-income youth often face inequities in access to nature. The purpose of this study was to evaluate the impact of a 15-week nature-based education (NBE) intervention on health-related quality of life (HRQoL) of low-income youth. METHODS: A total of 362 low-income youth (ages 9-15) in St. Louis, MO, USA, participated in this study. Study participants completed a pre- and post-intervention survey that included validated measures of six HRQoL domains (Physical Activity, Emotional Health Functioning, School Functioning, Social Functioning, Family Functioning and overall HRQoL). Random effects analysis of covariance was used to test for significant differences in HRQoL scores between the intervention and control groups, after adjusting for school, age, previous nature exposure, and Science, Technology, Engineering and Mathematics capacity. RESULTS: After the intervention period, youth in the NBE intervention group experienced improvements in all HRQoL domain scores (P < 0.001), whereas youth in the control group experienced declines in HRQoL domain scores (P < 0.001). CONCLUSIONS: NBE may have a positive impact on the HRQoL of low-income youth. Further investigations examining the influence of nature-based activities on youth health outcomes are warranted.

Keeping Each Other Safe: Who Checks on Their Neighbors During Weather Extremes in Summer and Winter?

OBJECTIVE: Weather extremes are increasing with climate change and associated with higher morbidity and mortality. Promotion of social connections is an emerging area of research and practice for risk reduction during weather extremes. This study examines the practice of checking on neighbors during extreme summer heat and extreme winter weather. Objectives are to (1) describe the extent of neighbor checking during these extremes, and (2) examine factors associated with neighbor checking. METHODS: We analyze survey data (n = 442) from a primarily low- and moderate- income study sample in a Southeastern U.S. city, using descriptive statistics and logistic regression. RESULTS: About 17.6% of participants checked on neighbors during extreme summer heat, and 25.2% did so during extreme winter weather. Being middle or older aged and having more adverse physical health impacts were positively associated with neighbor checking, for both extremes. For winter only, having less education was positively associated with neighbor checking. CONCLUSIONS: Community-based partnerships for reducing risk during weather extremes may consider people who are older or have experienced their own adverse health impacts as initial target groups for promoting neighbor checking. Future research should also examine the motivations for, details about, and impacts of neighbor checking in greater depth.

Erratum: Ekenga, C.; et al. Long-Term Employment Outcomes among Female Cancer Survivors. Int. J. Environ. Res. Public Health 2020, 17, 2751.

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An Analysis of the Educational and Health-Related Benefits of Nature-Based Environmental Education in Low-Income Black and Hispanic Children.

Background: Low-income and non-white children experience disparities in health, education, and access to nature. These health disparities are often associated and exacerbated by inequities in the U.S. educational system. Recent research suggests that nature contact may reduce these health and educational disparities for urban low-income populations. Nature-based education (NBE) uses nature contact to inspire curiosity and improve health. This study examines the health and educational outcomes of a 15-week NBE intervention for urban low-income, black and Hispanic children 10-15 years of age. Methods: Children (n=122) completed a pre-intervention and post-intervention survey that addressed seven science, technology, engineering, and math (STEM)-capacity items (leadership, teamwork, science relevance, sustainability relevance, STEM self-efficacy, science interest, and overall STEM capacity) and six widely used health-related quality-of-life (HRQoL) domains (physical health functioning, emotional health functioning, school functioning, social functioning, family functioning, and overall HRQoL). Focus groups with participating students and post-intervention surveys of NBE mentors and teachers explored perceptions of the intervention impact. Results: There were statistically significant positive changes in STEM capacity and HRQoL for participating students. For example, children's overall STEM capacity and overall HRQoL scores improved by 44% and 46%, respectively (both p<0.05). Qualitative data highlighted the intervention's educational and health benefits. Conclusions: These results support further research quantifying the effects of NBE on STEM capacity and HRQoL in urban, low-income, black and Hispanic children.

Mental Health and Weather Extremes in a Southeastern U.S. City: Exploring Group Differences by Race.

The connection between mental health and weather extremes is a public health concern, but less studied to date than physical health. This exploratory study examines the mental health impacts of two kinds of weather extremes increasingly linked to climate change-summer heat waves and extreme winter weather-in a low- to middle-income population in the Southeastern U.S. The distribution of mental health impacts, and potential pathways to them, are examined with a focus on race. Data are from a random-sample survey of 426 participants and are analyzed with bivariate statistics and path analysis. Self-reported mental health impacts, in both seasons, were common in our study, with White participants tending to report worse impacts than participants who identified with other racial groups. Physical health had direct effects on mental health across several models, overall and by racial group. For summer heat waves, concern about climate change and social cohesion had direct and indirect effects, respectively, on mental health in White participants only. For extreme winter weather, preparedness had a direct negative effect on mental health in White, but not Black, participants. Results suggest that there may be racial differences in the influence of human and social capital factors on mental health related to weather extremes, warranting further study of this critical topic and with larger racial subgroup samples.

Long-Term Employment Outcomes among Female Cancer Survivors.

Advances in early detection and treatment have led to a growing population of female cancer survivors, many of whom are of working age. We examined the relationship between cancer and long-term (>5 years) employment outcomes in a nationally representative sample of working-age women in the United States. Data from nine waves of the Health and Retirement Study were used to examine employment status and weekly hours worked among cancer survivors (n = 483) and women without cancer (n = 6605). We used random slope regression models to estimate the impact of cancer and occupation type on employment outcomes. There was no difference in employment status between cancer survivors and women without cancer at baseline; however, during follow-up, cancer survivors were more likely to be employed than women without cancer (odds ratio (OR) = 1.33, 95% confidence interval (CI): 1.11-1.58). Among 6-10-year survivors, professional workers were less likely (OR = 0.40, 95% CI: 0.21-0.74) to be employed than manual workers. Among >10-year survivors, professional workers averaged fewer weekly hours worked (-2.4 h, 95% CI: -4.4--0.47) than manual workers. The impact of cancer on long-term employment outcomes may differ by occupation type. Identifying the occupation-specific mechanisms associated with the return to work will be critical to developing targeted strategies to promote employment in the growing female cancer survivor population.

Adapting to Climate Change in the Upper Mississippi River Basin: Exploring Stakeholder Perspectives on River System Management and Flood Risk Reduction.

In the Midwestern United States (US), river flooding is a climate change-related hazard that poses a significant threat to health, well-being and economic stability. The 2019 Midwest floods led to major flooding at every monitoring site along the Mississippi River, set record water levels at 42 sites, and resulted in an estimated $6.2 billion in infrastructure damage and recovery costs. Although the risks associated with increasing flooding in the Midwestern US have been well recognized, less is known about the adaptation challenges and opportunities in the region, particularly in the Upper Mississippi River Basin. This exploratory study examined stakeholder perspectives on river system management, flood risk reduction, and adaptation planning in the Upper Mississippi River Basin. We conducted in-depth interviews with flood management stakeholders between August and October 2019. Interview data were analyzed using thematic analysis. Five themes emerged from the interviews: (1) River flooding in the Midwestern US is a different experience than US coastal flooding; (2) River flooding in the Midwestern US is a regional experience that requires a regional response; (3) Local actors face constrained resources for flood risk protection and recovery; (4) Differentiated responsibility across levels of governments makes recovery and response difficult to navigate; and (5) Competing stakeholder goals challenge cooperative flood hazard management. Overall, these results suggest that locally focused adaptation efforts, while perhaps appropriate for coastal communities or more urban contexts, are suboptimal strategies for communities in the flood-prone river basins of the Midwestern US. Instead, structures and support for regional collaboration should be considered and pursued.

A Prospective Study of Weight Gain in Women Diagnosed with Early-Stage Invasive Breast Cancer, Ductal Carcinoma In Situ, and Women Without Breast Cancer.

Background: Weight gain after breast cancer has been associated with recurrence and mortality. We therefore examined factors associated with ≥5% weight gain over 2-year follow-up of a cohort of newly diagnosed early-stage invasive breast cancer (EIBC) and ductal carcinoma in situ (DCIS) patients and age-matched controls without a breast cancer history. Materials and Methods: We interviewed participants 4-6 weeks after definitive surgical treatment (patients) or a negative/benign screening mammogram (controls). Multivariable logistic regression models were used to identify socioeconomic, psychosocial, and treatment factors associated with ≥5% weight gain over 2-year follow-up. Results: Overall, 88 (24%) of 362 EIBC patients, 31 (17%) of 178 DCIS patients, and 82 (15%) of 541 controls had ≥5% weight gain during follow-up. EIBC patients were more likely to experience ≥5% weight gain than DCIS patients (Odds ratio [OR] = 2.16; 95% confidence interval [95% CI] = 1.19-3.95) and controls (OR = 1.76; 95% CI = 1.23-2.51). Among EIBC patients, older patients (OR = 0.96; 95% CI = 0.93-0.99), patients who underwent endocrine therapy (OR = 0.43; 95% CI = 0.19-0.95), smokers (OR = 0.35; 95% CI = 0.14-0.86), and African Americans (OR = 0.23; 95% CI = 0.09-0.58) were less likely to have ≥5% weight gain than their respective counterparts. Among DCIS patients, older patients (OR = 0.94; 95% CI = 0.89-0.99) were less likely to have ≥5% weight gain. Among controls, smokers were more likely to have ≥5% weight gain (OR = 3.03; 95% CI = 1.49-6.17). Conclusions: EIBC patients were more likely than DCIS patients and controls to experience ≥5% weight gain over follow-up. Studies are necessary to elucidate mechanisms of weight gain in early-stage breast cancer survivors.

Cancer risk from air toxics in relation to neighborhood isolation and sociodemographic characteristics: A spatial analysis of the St. Louis metropolitan area, USA.

BACKGROUND: A growing body of research has examined relationships between neighborhood characteristics and exposure to air toxics in the United States. However, a limited number of studies have addressed neighborhood isolation, a measure of spatial segregation. We investigated the spatial distribution of carcinogenic air toxics in the St. Louis metropolitan area and tested the hypothesis that neighborhood isolation and sociodemographic characteristics are associated with exposure to carcinogenic air toxics. METHODS: We obtained lifetime air toxics cancer risk data from the United States Environmental Protection Agency's National Air Toxic Assessment and sociodemographic data from the American Community Survey. We used geographic information systems to identify statistically significant clusters of census tracts with elevated all-site cancer risk due to air toxics in the St. Louis metropolitan area. Relative Risks (RR) were estimated for the association between neighborhood characteristics and air toxic hot spots. Using a local spatial isolation index to evaluate residential segregation, we also evaluated the association between neighborhood racial and economic isolation and air toxic hot spots. RESULTS: Approximately 14% (85 of the 615) of census tracts had elevated cancer risk due to air toxics (p < 0.01). These air toxic hot spots were independently associated with neighborhoods with high levels of poverty and unemployment and low levels of education. Census tracts with the highest levels of both racial isolation of Blacks and economic isolation of poverty were more likely to be located in air toxic hotspots than those with low combined racial and economic isolation (RR = 5.34; 95% CI = 3.10-9.22). CONCLUSIONS: These findings provide strong evidence of unequal distribution of carcinogenic air toxics in the St. Louis metropolitan area. Study results may be used to inform public health efforts to eliminate sociodemographic inequalities in exposure to air pollutants.

Gender and Public Health Emergency Preparedness Among United States Adults.

Public health emergency preparedness can improve a community's ability to cope health outcomes associated with environmental disasters and complex emergencies. Previous studies of gender and preparedness have yielded mixed results. The objective of this study was to examine the association between gender and public health emergency preparedness among U.S. adults using data from the behavioral risk factors surveillance system (BRFSS). Data was analyzed from the 2006-2012 BRFSS for 96,137 adults from 10 states. Three self-reported preparedness behaviors were evaluated: household preparedness (3-day supply of water, 3-day supply of food, battery-operated radio, and flashlight), emergency evacuation plan, and 3-day supply of medication. Multivariable log-binomial regression was used to estimate associations between gender and each preparedness behavior. Gender-specific regression analyses were also conducted to identify determinants of public health emergency preparedness. After adjusting for sociodemographic characteristics, women were less likely to report household preparedness (PR 0.71, 95% CI 0.67-0.75) and a 3-day supply of medication (PR 0.89, 95% CI 0.79-0.99) than men. Among women, being divorced, widowed or separated (PR 0.84, 95% CI 0.71, 1.00) and living in a household with children (PR 0.84, 95% CI 0.77, 0.92) was inversely associated with reported household preparedness. This study adds to the epidemiology literature regarding gender and preparedness behaviors in the United States. Future investigations are warranted to confirm these findings and inform practices aimed at improving public health emergency preparedness.

The global environmental injustice of fast fashion.

Fast fashion, inexpensive and widely available of-the-moment garments, has changed the way people buy and dispose of clothing. By selling large quantities of clothing at cheap prices, fast fashion has emerged as a dominant business model, causing garment consumption to skyrocket. While this transition is sometimes heralded as the "democratization" of fashion in which the latest styles are available to all classes of consumers, the human and environmental health risks associated with inexpensive clothing are hidden throughout the lifecycle of each garment. From the growth of water-intensive cotton, to the release of untreated dyes into local water sources, to worker's low wages and poor working conditions; the environmental and social costs involved in textile manufacturing are widespread.In this paper, we posit that negative externalities at each step of the fast fashion supply chain have created a global environmental justice dilemma. While fast fashion offers consumers an opportunity to buy more clothes for less, those who work in or live near textile manufacturing facilities bear a disproportionate burden of environmental health hazards. Furthermore, increased consumption patterns have also created millions of tons of textile waste in landfills and unregulated settings. This is particularly applicable to low and middle-income countries (LMICs) as much of this waste ends up in second-hand clothing markets. These LMICs often lack the supports and resources necessary to develop and enforce environmental and occupational safeguards to protect human health. We discuss the role of industry, policymakers, consumers, and scientists in promoting sustainable production and ethical consumption in an equitable manner.