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National Institute of Environmental Health Sciences

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A Review of Urban Planning Approaches to Reduce Air Pollution Exposures

• Dung-Ying Lin
• S. Travis Waller
• Ming-Yeng Lin

Exposure to Endocrine Disruptors in Early life and Neuroimaging Findings in Childhood and Adolescence: a Scoping Review

• Kim N. Cajachagua-Torres
• Hugo G. Quezada-Pinedo
• Akhgar Ghassabian

Exposure to Synthetic Endocrine-Disrupting Chemicals in Relation to Maternal and Fetal Sex Steroid Hormones: A Scoping Review

• Megan C. Hansel
• Abigail M. Rosenberg
• Emily S. Barrett

Advancing Understanding of Chemical Exposures and Maternal-child Health Through the U.S. Environmental Influences on Child Health Outcomes (ECHO) Program: A Scoping Review

• Jennifer L. Ames
• for the ECHO Cohort Consortium

Tear Fluid as a Matrix for Biomonitoring Environmental and Chemical Exposures

• Parshawn Amini
• Joseph O. Okeme

Metabolic Perturbations Associated with both PFAS Exposure and Perinatal/Antenatal Depression in Pregnant Individuals: A Meet-in-the-Middle Scoping Review

• Himal Suthar
• Roselyn B. Tanghal

Health Effects of Occupational and Environmental Exposures to Nuclear Power Plants: A Meta-Analysis and Meta-Regression

• Ro-Ting Lin
• Hathaichon Boonhat
• Ken Takahashi

Environmental and Human Health Problems Associated with Hospital Wastewater Management in Zimbabwe

• Steven Jerie
• Timothy Vurayayi Mutekwa
• Takunda Shabani

Portable x-ray fluorescence for bone lead measurement: Current approaches and future directions

• Aaron J. Specht
• Christian Hoover
• Thomas Grier

Contributions of Synthetic Chemicals to Autoimmune Disease Development and Occurrence

• Noelle N. Kosarek
• Emma V. Preston

Environmental Justice and Health in Nigeria

• Toluwalope Ogunro

The Environment and Headache: a Narrative Review

• Holly Elser
• Caroline F. G. Kruse
• Joan A. Casey

Reproductive and Social Policies, Sociopolitical Stress, and Implications for Maternal and Child Health Equity

• Stephanie M. Eick
• Jasmin A. Eatman
• Nina R. Brooks

Correction: The Health-Related and Learning Performance Effects of Air Pollution and Other Urban-Related Environmental Factors on School-Age Children and Adolescents—A Scoping Review of Systematic Reviews

• Inés Valls Roche
• Mònica Ubalde-Lopez
• Mireia Gascon

Health Disparities in the Aftermath of Flood Events: A Review of Physical and Mental Health Outcomes with Methodological Considerations in the USA

• Aaron B. Flores
• Jonathan A. Sullivan
• Hannah K. Friedrich

Addressing Health Equity in the Context of Carbon Capture, Utilization, and Sequestration Technologies

• David Rojas-Rueda
• Kelly McAuliffe
• Emily Morales-Zamora

Unpacking Neighborhood Socioeconomic Status in Children’s Health Research from an Environmental Justice Perspective: A Scoping Review

• Ananya Bhaktaram
• Amii M. Kress
• Emily A. Knapp

Epigenetic Responses to Nonchemical Stressors: Potential Molecular Links to Perinatal Health Outcomes

• Lauren A. Eaves
• Cailee E. Harrington
• Rebecca C. Fry

Existing Challenges and Opportunities for Advancing Drought and Health Research

• Jesse D. Berman
• Azar M. Abadi
• Jesse E. Bell

Consideration on the Intergenerational Ethics on Uranium Waste Disposal

• Hiroshi Yasuda
• Hiromichi Fumoto
• Shoji Tsuchida

Public Health Risks of PFAS-Related Immunotoxicity Are Real

• Abigail P. Bline
• Jamie C. DeWitt
• Julia R. Varshavsky

Opportunities and Challenges Associated with the Uptake of Residential Clean Fuel Usage

• Sohail Ahmad
• Joshua Kirshner

Airborne Exposure to Pollutants and Mental Health: A Review with Implications for United States Veterans

• Andrew J. Hoisington
• Kelly A. Stearns-Yoder
• Lisa A. Brenner

The Association Between Personal Air Pollution Exposures and Fractional Exhaled Nitric Oxide (FeNO): A Systematic Review

• Abhay Anand
• Elliana Castiglia
• Misti Levy Zamora

Methods for the Analysis of Multiple Epigenomic Mediators in Environmental Epidemiology

• Arce Domingo-Relloso
• Maria Tellez-Plaza
• Linda Valeri

The Health-Related and Learning Performance Effects of Air Pollution and Other Urban-Related Environmental Factors on School-Age Children and Adolescents—A Scoping Review of Systematic Reviews

Supporting Decarbonization of Health Systems—A Review of International Policy and Practice on Health Care and Climate Change

• Emily Hough
• Arielle Cohen Tanugi-Carresse

A Review of the Interactive Effects of Climate and Air Pollution on Human Health in China

• Tiantian Li

Challenges of Air Pollution and Health in East Asia

• Renjie Chen
• Haidong Kan

Time to Treat the Climate and Nature Crisis as One Indivisible Global Health Emergency

• Kamran Abbasi
• Parveen Ali
• Chris Zielinski

Toxicological Effects of Inhaled Crude Oil Vapor

• Jeffrey S. Fedan
• Janet A. Thompson
• Stacey E. Anderson

Climate Change Adaptation Methods for Public Health Prevention in Australia: an Integrative Review

• Tony G. Walter
• Lisa K. Bricknell
• Elise G. C. Crawford

Respiratory Exposure to Highly Fluorinated Chemicals via Application of Ski Wax and Related Health Effects

• Kathryn A. Crawford
• Nicola Hartmann

Conceptualizing the Role of the Microbiome as a Mediator and Modifier in Environmental Health Studies: A Scoping Review of Studies of Triclosan and the Microbiome

• Hannah E. Laue
• Aislinn J. Gilmour
• Megan E. Romano

The Application of Nature-Based Solutions for Urban Heat Island Mitigation in Asia: Progress, Challenges, and Recommendations

• Logaraj Ramakreshnan
• Nasrin Aghamohammadi

Current Trends and Future Directions in Urban Social Prescribing

• L. Coll-Planas

Air Pollution and Lung Cancer: Contributions of Extracellular Vesicles as Pathogenic Mechanisms and Clinical Utility

• Jonathan González-Ruíz
• Andrea A.Baccarelli
• Diddier Prada

Health Impacts of Wildfire Smoke on Children and Adolescents: A Systematic Review and Meta-analysis

• Yiwen Zhang
• Ye Tingting
• Shanshan Li

Influence of Air Pollution Exposures on Cardiometabolic Risk Factors: a Review

• Mohammed Zeeshan
• Guang-Hui Dong

A scoping review of multigenerational impacts of grandparental exposures on mental health in grandchildren

• Jingyuan Xiao
• Anushka Jain

Asthma and Environmental Exposures to Phenols, Polycyclic Aromatic Hydrocarbons, and Phthalates in Children

• Medina S. Jackson-Browne
• Marisa A. Patti
• Wanda Phipatanakul

Global Research on Natural Disasters and Human Health: a Mapping Study Using Natural Language Processing Techniques

Association between Asbestos Exposure and the Incidence of Kidney Cancer: a Weight-of-Evidence Evaluation and Meta-analysis

• Fu-Shiuan Whitney Lee
• Yu-Han Chen

Control Banding and the Global Rise of Qualitative Risk Assessment Strategies

• Juliana H. Halbach
• John M. Cala
• David M. Zalk

Fluoride Exposure and Skeletal Fluorosis: a Systematic Review and Dose-response Meta-analysis

• Federica Veneri
• Inga Iamandii
• Tommaso Filippini

Air Pollution and Temperature: a Systematic Review of Ubiquitous Environmental Exposures and Sudden Cardiac Death

• William Borchert
• Stephanie T. Grady
• Jaime E. Hart

Synthetic Chemicals: What We Have Learned and Still Need to Learn About Their Associations with Childhood Allergy and Asthma

• Rachel L. Miller

Role of Metals on SARS-CoV-2 Infection: a Review of Recent Epidemiological Studies

• Khalid M. Khan
• Mariah J. Zimpfer
• Faruque Parvez

Exposure to Organochlorine Pesticides and Female Breast Cancer Risk According to Molecular Receptors Expression: a Systematic Review and Meta-analysis of Epidemiological Evidence

• Rodrigo Ugalde-Resano
• Brenda Gamboa-Loira
• Lizbeth López-Carrillo

Methods in Public Health Environmental Justice Research: a Scoping Review from 2018 to 2021

• Misbath Daouda
• Tamarra James-Todd

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Access to Green Spaces May Help Prevent Cognitive Decline

A study co-authored by Francine Laden, SD, Jaime Hart, SD, and Peter James, SD, found that living in greener neighborhoods during middle-age years may improve cognitive function and slow cognitive decline. Dr. Laden, Associate Chair of Environmental Health, Dr. Hart, Associate Professor of Environmental Health, and Dr. James, Adjunct Associate Professor of Environmental Health, focused on the cognitive benefits of green space for carriers of the APOE-ɛ4 gene who have a higher risk of Alzheimer’s disease.

What System is Best for Measuring Extreme Heat?

Dr. Joseph Allen, Associate Professor in the Department of Environmental Health, advocates for the widespread adoption of the “wet-bulb globe temperature” system.

“What matters is not how hot the air is but how hot the weather is to a human body. For that, we need “wet-bulb globe temperature,” states Dr. Allen.

New Model Could Help Provide Expectant Mothers a Clearer Path to Safe Fish Consumption

Fish consumption is an important route of methyl mercury exposure, however, efforts to understand the health risk posed by mercury are further complicated by the fact that the nutritional benefits from fish may modify or reduce the toxicity posed by mercury. A new study co-authored by Susan Korrick, Assistant Professor in the Department of Environmental Health, creates a new framework that could untangle these questions, reduce confusion, and produce clearer guidance on fish consumption for pregnant mothers.

The Disturbing Truth About Hair Relaxers

A recent New York Times Magazine article featured Tamarra James-Todd, Associate Professor of Environmental Reproductive Epidemiology, and her research concerning endocrine disrupting chemicals in hair relaxers, as well as other commonly used hair products, and Black women’s health. The article shows how environmental health science can be used for action to improve consumer product chemical safety.

‘Linear Urban Forest’ Project Aims to Mitigate Heat, Improve Health in Cities

“Without natural spaces, heat gets concentrated, and that concentration of heat—which is worsening due to climate change—is dangerous for people to live in, recreate in, and work in,” explains Linda Powers Tomasso, Research Fellow in the Department of Environmental Health.

Tomasso and John Spengler, Akira Yamaguchi Professor of Environmental Health and Human Habitation, recently presented visualizations of the linear forest designs to Springfield residents, to offer them a “you-are-there” picture of what it would be like to live amid more greenery, talk about how it could improve their health, and gather their feedback.

‘Boot Camp’ Draws Researchers Focused on Environmental Health Disparities

“Built into environmental justice is the need to identify a problem and develop or design a solution that can be testable and improved upon, " said Tamarra James-Todd, Mark and Catherine Winkler Associate Professor of Environmental Reproductive Epidemiology.

Helping maintain and improve the health of all people through global leadership in environmental health research and training.

As Chair and Associate Chair of the Department of Environmental Health, we welcome you to our website. For more than 100 years, our Department has advanced the field of Environmental Health through hands-on learning and training, and translates evidence-based on research. We have a vibrant and rich history of guiding public discourse, and national and international leaders, on the most pressing environmental health challenges in the twenty-first-century. To better serve communities’ changing health, we employ innovative strategies and solutions to increase public awareness. Our work in laboratories, field studies, and cohort studies has provided the basis of environmental and occupational health on humans, and solutions therein. Members of our Department create and advance our knowledge of harmful exposures and translate their discoveries into actions that ultimately improve people’s health. Our centers, faculty, students, and staff engage in service activities to expand the capacity of communities by training, mentoring, and empowering the next world leaders.

News from the School

Air pollution exposure in infancy may limit economic mobility in adulthood

Reducing health inequities in the Mississippi Delta

Climate change and planetary health concentration launches

Orientation 2024: New students encouraged to engage across differences

Environmental Health

Author instructions.

Before submitting your manuscript with us, please carefully consider our  submission guidelines .

Note that the journal only publishes content that covers areas of environmental science in which human health and well-being are involved and won’t consider other aspects of environmental sciences. 

Editors' Choice

Long-term ambient air pollution exposure and renal function and biomarkers of renal disease.

Despite accumulating evidence of an association between air pollution and renal disease, studies on the association between long-term exposure to air pollution and renal function are still contradictory. This study aimed to investigate this association in a large population with relatively low exposure and with improved estimation of renal function as well as renal injury biomarkers.

Author: Karl Kilbo Edlund, Yiyi Xu, Eva M. Andersson, Anders Christensson, Mats Dehlin, Helena Forsblad-d’Elia, Florencia Harari, Stefan Ljunggren, Peter Molnár, Anna Oudin, Magnus Svartengren, Petter Ljungman & Leo Stockfelt  Content type: Research Published on: 09 August 2024

Exposure to heavy metals in utero and autism spectrum disorder at age 3: a meta-analysis of two longitudinal cohorts of siblings of children with autism

Autism spectrum disorder is a prevalent and heterogeneous neurodevelopmental disorder. Risk is attributed to genetic and prenatal environmental factors, though the environmental agents are incompletely characterized.

Authors:  John F. Dou, Rebecca J. Schmidt, Heather E. Volk, Manon M. Nitta, Jason I. Feinberg, Craig J. Newschaffer, Lisa A. Croen, Irva Hertz-Picciotto, M. Daniele Fallin & Kelly M. Bakulski  Content type: Research Published on: 05 July 2024

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The effect of alcohol consumption on human physiological and perceptual responses to heat stress: a systematic scoping review

Authors: Nathan B. Morris, Nicholas Ravanelli and Georgia K. Chaseling

Trajectories of long-term exposure to PCB153 and Benzo[a]pyrene (BaP) air pollution and risk of breast cancer

Authors: Pauline Desnavailles, Delphine Praud, Blandine Le Provost, Hidetaka Kobayashi, Floriane Deygas, Amina Amadou, Thomas Coudon, Lény Grassot, Elodie Faure, Florian Couvidat, Gianluca Severi, Francesca Romana Mancini, Béatrice Fervers, Cécile Proust-Lima and Karen Leffondré

Pre-natal and early life lead exposure and childhood inhibitory control: an item response theory approach to improve measurement precision of inhibitory control

Authors: Shelley H. Liu, Yitong Chen, David Bellinger, Erik de Water, Megan Horton, Martha M. Téllez-Rojo and Robert Wright

Greater exposure to PM 2.5 and PM 10 was associated with lower corneal nerve measures: the Maastricht study - a cross-sectional study

Authors: Sara B. A. Mokhtar, Jessica Viljoen, Carla J. H. van der Kallen, Tos T. J. M. Berendschot, Pieter C. Dagnelie, Jeroen D. Albers, Jens Soeterboek, Fabio Scarpa, Alessia Colonna, Frank C. T. van der Heide, Marleen M. J. van Greevenbroek, Hans Bosm, Abraham A. Kroon, Rudy M. M. A. Nuijts, Marlies Gijs, Jeroen Lakerveld…

Urinary polycyclic aromatic hydrocarbon metabolites and their association with oxidative stress among pregnant women in Los Angeles

Authors: Qi Meng, Sanjali Mitra, Irish Del Rosario, Michael Jerrett, Carla Janzen, Sherin U. Devaskar and Beate Ritz

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The global environmental injustice of fast fashion

Authors: Rachel Bick, Erika Halsey and Christine C. Ekenga

The Bhopal disaster and its aftermath: a review

Authors: Edward Broughton

Mercury from chlor-alkali plants: measured concentrations in food product sugar

Authors: Renee Dufault, Blaise LeBlanc, Roseanne Schnoll, Charles Cornett, Laura Schweitzer, David Wallinga, Jane Hightower, Lyn Patrick and Walter J Lukiw

Human health implications of organic food and organic agriculture: a comprehensive review

Authors: Axel Mie, Helle Raun Andersen, Stefan Gunnarsson, Johannes Kahl, Emmanuelle Kesse-Guyot, Ewa Rembiałkowska, Gianluca Quaglio and Philippe Grandjean

Aspartame and cancer – new evidence for causation

Authors: Philip J. Landrigan and Kurt Straif

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Editors-in-Chief

Philippe Grandjean, University of Southern Denmark, Denmark

Ruth Etzel, Milken Institute School of Public Health, The George Washington University, USA

Aims and scope

Environmental Health publishes manuscripts on important aspects of environmental and occupational medicine and related studies in toxicology and epidemiology that elucidate the human health implications of exposures to environmental hazards. Environmental Health articles are published with open access, and the journal operates a single-blind peer-review system. The journal is aimed at scientists and practitioners in all areas of environmental science in which human health and well-being are involved, either directly or indirectly, and with a view to improving the prevention of environmentally-related risks to human health. Environmental Health is a public health journal serving the public health community and scientists working on matters of public health interest and importance pertaining to the environment. Before submitting a manuscript, please see our submission guidelines for author guidance. 

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Environmental Health operates a single-blind peer-review system, where the reviewers are aware of the names and affiliations of the authors, but the reviewer reports provided to authors are anonymous. For more information, see our peer-review policy .  

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Annual Journal Metrics

Citation Impact 2023 Journal Impact Factor: 5.3 5-year Journal Impact Factor: 6.7 Source Normalized Impact per Paper (SNIP): 1.348 SCImago Journal Rank (SJR): 1.228

Speed 2023 Submission to first editorial decision (median days): 3 Submission to acceptance (median days): 119

Usage 2023 Downloads: 2,144,579 Altmetric mentions: 5,304

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ISSN: 1476-069X

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Environmental Research: Health is a multidisciplinary, open access journal devoted to addressing important global challenges at the interface of the environment and public health in a way that bridges scientific progress and assessment with efforts relating to impact/future risks, resilience, mitigation, adaptation, security and solutions in the broadest sense. All research methodologies are encouraged comprehensively covering qualitative, quantitative, experimental, theoretical and applied approaches; exposure assessments; implementation studies; and policy analysis. For detailed information about subject coverage see the About the journal section.

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Jonathan J Buonocore et al 2023 Environ. Res.: Health 1 021006

Oil and gas production is one of the largest emitters of methane, a potent greenhouse gas and a significant contributor of air pollution emissions. While research on methane emissions from oil and gas production has grown rapidly, there is comparatively limited information on the distribution of impacts of this sector on air quality and associated health impacts. Understanding the contribution of air quality and health impacts of oil and gas can be useful for designing mitigation strategies. Here we assess air quality and human health impacts associated with ozone, fine particulate matter, and nitrogen dioxide from the oil and gas sector in the US in 2016, and compare this impact with that of the associated methane emissions. We find that air pollution in 2016 from the oil and gas sector in the US resulted in 410 000 asthma exacerbations, 2200 new cases of childhood asthma and 7500 excess deaths, with $77 billion in total health impacts. NO 2 was the highest contributor to health impacts (37%) followed by ozone (35%), and then PM 2.5 (28%). When monetized, these air quality health impacts of oil and gas production exceeded estimated climate impact costs from methane leakage by a factor of 3. These impacts add to the total life cycle impacts of oil and gas, and represent potential additional health benefits of strategies that reduce consumption of oil and gas. Policies to reduce oil and gas production emissions will lead to additional and significant health benefits from co-pollutant reductions that are not currently quantified or monetized.

Malcolm N Mistry and Antonio Gasparrini 2024 Environ. Res.: Health 2 035011

The development of innovative tools for real-time monitoring and forecasting of environmental health impacts is central to effective public health interventions and resource allocation strategies. Though a need for such generic tools has been previously echoed by public health planners and regional authorities responsible for issuing anticipatory alerts, a comprehensive, robust and scalable real-time system for predicting temperature-related excess deaths at a local scale has not been developed yet. Filling this gap, we propose a flexible operational framework for coupling publicly available weather forecasts with temperature-mortality risk functions specific to small census-based zones, the latter derived using state-of-the-art environmental epidemiological models. Utilising high-resolution temperature data forecast by a leading European meteorological centre, we demonstrate a real-time application to forecast the excess mortality during the July 2022 heatwave over England and Wales. The output, consisting of expected temperature-related excess deaths at small geographic areas on different lead times, can be automated to generate maps at various spatio-temporal scales, thus facilitating preventive action and allocation of public health resources in advance. While the real-case example discussed here demonstrates an application for predicting (expected) heat-related excess deaths, the framework can also be adapted to other weather-related health risks and to different geographical areas, provided data on both meteorological exposure and the underlying health outcomes are available to calibrate the associated risk functions. The proposed framework addresses an urgent need for predicting the short-term environmental health burden on public health systems globally, especially in low- and middle-income regions, where rapid response to mitigate adverse exposures and impacts to extreme temperatures are often constrained by available resources.

Suellen Hopfer et al 2024 Environ. Res.: Health 2 035013

Families in unincorporated communities in Southern California's Eastern Coachella Valley (ECV) increasingly experience the burden of repeat wildfires and smoke. This study describes their lived wildfire and smoke experiences, health impacts, unique community-level inequities that compound wildfire risk and air quality effects, communication preferences, and resource needs for future wildfire preparedness. A wildfire community vulnerability framework informed the focus group discussion guide, exploring individual, community, and local government level factors that potentially influence community response and mitigation behaviors to repeat wildfire and smoke. Ten focus groups with 118 participants occurred in spring 2023 with four communities in ECV, California. Findings center on narratives of acute wildfire-related experiences, including evacuation and burned trailer homes, acute and chronic self report physical and mental health impacts of wildfires and smoke, daily life disruptions, staying indoors for protection, and local interactions described as a community strength in responding to fires. Participants from unincorporated, low-income, and monolingual Spanish-speaking communities predominantly consisting of farm workers requested greater emergency preparedness and response information, training and education in Spanish, postfire resources, lower trash service fees, increased enforcement of illegal dumping and burning, and use of multimodal and bilingual communication channels for wildfire, smoke, and wind alerts.

Sahil Bhandari et al 2024 Environ. Res.: Health 2 035012

Odors are a topic of emerging environmental health interest given their potential links to air quality, health, well-being, and quality of life. However, odors have traditionally been challenging to study given variability in individual sensitivity and perception, atmospheric physico-chemical processes, and emissions of mixtures of odorous contaminants. Here, we explore the potential utility of crowd-sourced odor report data in improving understanding of spatiotemporal patterns of odor experiences and their impacts. We conduct quantitative and qualitative analyses of a 12-month data set from a web application collecting crowd-sourced odor reports, including spatiotemporal information, odor and self-reported impacts description (OSAC: odors, symptoms, actions in response, and suspected causes), and demographics, in Vancouver, Canada. Users report diverse OSAC with strong seasonality and spatial variability. Reported symptoms, ranging from neurological to emotion- and mood-related, highlight the complexity of odor-related health and well-being impacts. Odors can trigger maladaptive actions, where individuals are exposed to other environmental stressors (e.g. heat stress) or curtail healthy behaviors (e.g. exercising outside) to cope with odor impacts. Clustering analysis of OSAC suggests that odor exposures may be linked to health, well-being, and quality of life impacts through complex mechanisms, related not only to the odor experienced but also perceived causes. Spatiotemporal patterns in reports highlight the potential influence of persistent sources (e.g. waste management) and transient events (e.g. accidents). Exploratory multiple linear regression models suggest that monitoring of air quality and meteorology may be insufficient to capture odor issues. Overall, these results suggest that crowd-sourced science incorporating self-reported health and well-being effects and behavioral responses can enrich understanding of the impacts of odorous emissions at large spatiotemporal scales and complement traditional air pollution monitoring.

Raksha Pandya-Wood et al 2024 Environ. Res.: Health 2 032002

In Malaysia, climate change typically manifests as frequent and extreme weather events. The effects on human health of such meteorological and ecological imbalances are multiple and diverse. Urgent attention is needed to address the health-related threats facing Malaysia as a result of climate change. This systematic review (SR) of available evidence adopted Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and identified and assessed a broad range of English language empirical, published research and excluded grey literature. Bias and quality of articles was assessed using Mixed Methods Assessment Tool. Using the search engines Scopus, PubMed, Ovid EMBASE, Web of Science, and EBSCO Host Medline, n = 374 results were yielded. Of these, after checking, n = 23 studies were examined. The studies can be grouped into three climatic themes Exposure , Outcomes and Planning . Our review confirms that urgent funding and investment is needed for larger-scale intervention studies on each of these themes. We observed a scarcity of high-quality empirical research, a preponderance of modelling studies to project and simulate scenarios, and a limited number of qualitative studies. Particular gaps in knowledge exist on climate change impacts on health in population groups in terms of demographic intersections to support these epidemiological data and simulation pathways. Furthermore, there was an absence of data on various topics concerning the effects of climate change on, for example, mental health, women, older people and/or the effects of displacement. The limitations of this work include accepting only English language publications and presenting only empirical studies. The study was not funded but was managed by the Monash Climate Change Communication Research node. This SR was registered on PROSPERO ID: CRD42023431868.

Daniel J Smith et al 2023 Environ. Res.: Health 1 032001

Climate change, the greatest public health threat of the 21st century, will uniquely affect rural areas that are geographically isolated and experience greater health inequities. This systematic review describes and evaluates interventions to lessen the effects of climate change on human health in the rural United States, including interventions on air pollution, vector ecology, water quality, severe weather, extreme heat, allergens, and water and food supply. Searches were constructed based on the eight domains of the Centers for Disease Control and Prevention (CDC) Framework "Impact of Climate Change on Human Health." Searches were conducted in EBSCO Environment Complete, EBSCO GreenFILE, Embase.com, MEDLINE via PubMed, and Web of Science. Duplicate citations were removed, abstracts were screened for initial inclusion, and full texts were screened for final inclusion. Pertinent data were extracted and synthesized across the eight domains. Article quality was assessed using the Mixed Methods Appraisal Tool. Of 8471 studies screened, 297 were identified for full text review, and a total 49 studies were included in this review. Across the domains, 34 unique interventions addressed health outcomes due to air pollution ( n = 8), changes in vector ecology ( n = 6), water quality ( n = 5), severe weather ( n = 3), extreme heat ( n = 2) increasing allergens ( n = 1), water and food supply ( n = 1), and across multiple CDC domains ( n = 8). Participatory action research methodology was commonly used and strived to mobilize/empower communities to tackle climate change. Our review identified three randomized controlled trials, with two of these three published in the last five years. While original research on the impact of climate change on health has increased in the past decade, randomized control trials may not be ethical, cost effective, or feasible. There is a need for time-efficient and high-quality scholarship that investigates intervention efficacy and effectiveness for reducing health impacts of climate change upon rural populations.

Kimberly A Terrell et al 2024 Environ. Res.: Health 2 021002

Previous studies indicate that pollution exposure can increase risks of adverse birth outcomes, but Black communities are underrepresented in this research, and the potential moderating role of neighborhood context has not been explored. These issues are especially relevant in Louisiana, which has a high proportion of Black residents, an entrenched history of structural racism, the most pounds of toxic industrial emissions annually, and among the nation's highest rates of low birthweight (LBW), preterm birth (PTB), and infant mortality. We investigated whether air pollution and social polarization by race and income (measured via the index of concentration at the extremes [ICE]) were associated with LBW and PTB among Louisiana census tracts ( n = 1101) using spatial lag models. Data sources included 2011–2020 birth records, U.S. Census Bureau 2017 demographic data, and 2017 respiratory hazard (RH) from the U.S. Environmental Protection Agency. Both RH and ICE were associated with LBW ( z = 4.4, P < 0.0001; z = −27.0, P < 0.0001) and PTB ( z = 2.3, P = 0.019; z = −16.7, P < 0.0001), with no interaction. Severely polluted tracts had 36% higher and 25% higher risks of LBW and PTB, respectively, versus unpolluted tracts. On average, 2166 low birthweight and 3583 preterm births annually were attributable to pollution exposure. Tracts with concentrated social deprivation (i.e. low ICE scores) had 53% higher and 34% higher risks of LBW and PTB, respectively, versus intermediate or mixed tracts. On average, 1171 low birthweight and 1739 preterm births annually were attributable to concentrated deprivation. Our ecological study found that a majority of adverse birth outcomes in Louisiana (i.e. 67% of LBW and PTB combined) are linked to air pollution exposure or disadvantage resulting from social polarization. These findings can inform research, policy, and advocacy to improve health equity in marginalized communities.

Kathleen E McLean et al 2024 Environ. Res.: Health 2 035010

Western North America experienced an unprecedented extreme heat event (EHE) in early summer 2021. In the province of British Columbia (BC), this event was associated with an estimated 740 excess deaths, making it one of the deadliest weather events in Canadian history. This study uses a population-based case-control design to compare 1597 adults (cases) who died during the EHE (25 June–2 July 2021) with 7968 similar adults (controls) who survived. The objective was to identify risk factors for death during the EHE by examining differences in chronic diseases and social vulnerability between the cases and controls. We used care setting, age category, sex, and geographic area of cases to identify comparable surviving controls. We used logistic regression to estimate the odds ratio (OR) for each chronic disease, adjusted for care setting, age category, sex, and geographic area. We further adjusted for individual-level low-income status to identify changes in the estimated ORs with the addition of this indicator of social vulnerability. The risk factor most strongly associated with EHE mortality was individual-level low income. The fully adjusted OR [95% confidence interval] for receiving income assistance was 2.42 [1.98, 2.95]. The chronic disease most strongly associated with EHE mortality was schizophrenia, with a fully adjusted OR of 1.93 [1.51, 2.45]. Chronic obstructive pulmonary disease, parkinsonism, heart failure, chronic kidney disease, ischemic stroke, and substance use disorder were also associated with significantly higher odds of EHE mortality. These results confirm the roles of social vulnerability, mental illness, and other specific underlying chronic conditions (renal, respiratory, cardiovascular, cerebrovascular, and neurological) in risk of mortality during EHEs. This information is being used to inform policy and planning to reduce risk during future EHEs in BC and across Canada.

Cassandra Jean et al 2024 Environ. Res.: Health 2 045002

Climate-sensitive hazards, including extreme heat, wildfire smoke, flooding, and rising sea levels, can jeopardize the health of all populations. However, certain population groups are more vulnerable to harm from these hazards. While youth–particularly those from historically marginalized groups and communities–are among those at the highest risk, their abilities may be underutilized in local climate adaptation efforts. This exploratory research aimed to identify opportunities for youth involvement in climate and environmental solutions in their historically marginalized communities. Specifically, this study (1) investigated youth risk perceptions and impacts of various climate-sensitive hazards (e.g. extreme heat, wildfire smoke, flooding, and sea level rise); (2) examined current barriers, resource needs, and opportunities for youth to engage in climate and environmental solution work; and (3) explored current methods and spaces where youth and community leaders can support youth-led climate-related initiatives. Through focus group discussions with youth and in-depth interviews with community leaders who are directly with youth, this study identified opportunities to leverage youth experiences, perceptions, and assets to promote a healthy and resilient community in the face of various compounding climate-related threats. Results showed that while youth recognize the changing climate and associated health impacts, they require more financial resources and support from local decision-makers to maintain their engagement and promote community resilience. Engaging youth in climate action and community resilience involves more than just centering youth voices and perspectives–it requires intentional collaboration, capacity-building, organizing, granting decision-making power, and other strategies to produce inclusive, intersectional, and sustainable solutions.

Kathleen Fitzsimmons et al 2024 Environ. Res.: Health 2 031004

A statewide air quality advisory was issued in Massachusetts for 6–7 June 2023 due to smoke originating from wildfires in Canada. Of particular concern was fine particulate matter, which has an aerodynamic diameter of ⩽2.5 μ m (PM 2.5 ) and has been linked to adverse respiratory outcomes. The objective of this study was to rapidly assess the impact of this wildfire smoke event on respiratory-related emergency department (ED) visits among Massachusetts residents. For exposure, daily air quality index (AQI) data from the US Environmental Protection Agency were used. Massachusetts counties, where for each day from 6 to 8 June 2023, the daily AQI was ⩾101 (i.e. unhealthy air quality), were considered exposed. For each exposed period, two unexposed reference periods where AQI < 101 (i.e. 'good' or 'moderate' air quality) were identified within the two weeks prior to the exposed period, with the same days of the week and in the same county. Data from the Massachusetts Department of Public Health's syndromic surveillance system were used to examine daily counts of ED visits for asthma, air-quality-related respiratory illness, and all causes by county of residence, age group, race, and Hispanic/Latino ethnicity. For each outcome, the numbers of ED visits were compared between the exposed and reference periods. Overall, there were no large increases in ED visits for any conditions examined during this wildfire smoke event. However, residents who were aged 18–64 years, Hispanic/Latino or White experienced small but not statistically significant increases in asthma-related ED visits. These potential differences in the effect on asthma-related ED visits by age and race/ethnicity may be relevant for analyses of future events. This study provides an example of how real-time, publicly available exposure data can be used in conjunction with outcome data from syndromic surveillance to rapidly examine the impact of wildfires and other acute environmental events on health.

Latest articles

Hanna Jardel et al 2024 Environ. Res.: Health 2 045004

As wildfire frequency and severity increases, smoke exposures will cause increasingly more adverse respiratory effects. While acute respiratory effects of smoke exposure have been documented in children, longer term sequelae are largely unstudied. Our objective here was to examine the association between gestational and postnatal exposure to wildfire smoke and prolonged use of prescription medication for respiratory conditions in early childhood. Using Merative MarketScan claims data, we created cohorts of term children born in western states between 1 January 2010–31 December 2014 followed for at least three years. Using NOAA Hazard Mapping System data, we determined the average number of days a week that >25% of the population in a metropolitan statistical area (MSA) was covered by smoke within each exposure period. The exposure periods were defined by trimester and two 12 week postnatal periods. Medication use was based on respiratory indication (upper respiratory, lower respiratory, or any respiratory condition) and categorized into outcomes of prolonged use (⩾30 d use) (PU) and multiple prolonged uses (at least two prolonged uses) (MPU). We used logistic regression models with random intercepts for MSAs adjusted for child sex, birth season, and birth year. Associations differed by exposure period and respiratory outcome, with elevated risk of MPU of lower respiratory medications following exposure in the third trimester and the first 12 postnatal weeks (RR 1.15, 95% CI 0.98, 1.35; RR 1.21, 95% CI 1.05, 1.40, respectively). Exposure in the third trimester was associated with an increase in MPU of any respiratory among males infants only (male RR 1.22, 95% CI 1.00, 1.50; female RR 0.93, 95% CI 0.66, 1.31). Through novel use of prescription claims data, this work identifies critical developmental windows in the 3rd trimester and first 12 postnatal weeks during which environmental inhalational disaster events may impact longer-term respiratory health.

Qasim Mehdi and Petros Vasilakos 2024 Environ. Res.: Health 2 045003

This paper examines how air quality improvements due to the 100% decarbonization of the US power sector in 2040 can reduce asthma exacerbation among children disaggregated by poverty status, race, and geography. Using spatial datasets that differentiate asthma prevalence by income, race, and state, we find that children living in households with income below the poverty line receive a disproportionate share of the benefits. To obtain these results, we employ several different federally administered datasets: American Community Survey, Behavioral Risk Factor Surveillance System (BRFSS), and Poverty Thresholds as provided by the US Census. We find that Black children and poor children, on average, have higher reductions in exposure to PM2.5. Nationally, close to 235 372 asthma exacerbation cases will be averted in 2040 under the decarbonization policy compared with Business-as-Usual. States with significant gains in asthma cases averted per 100 000 are Indiana, Kentucky, Ohio, Missouri, Pennsylvania, Texas, and Wisconsin. Furthermore, since the asthma portion of the BRFSS is not conducted in South Carolina, Colorado, Arkansas, and South Dakota, these states were omitted from the analysis. Across all states with significant gains, children living below the poverty line have larger health benefits than children above the poverty line. Households with child poverty have 50% larger reductions in asthma exacerbations than households without childhood poverty. Black children below the poverty line experience 33% higher health gains compared to Black children per 100 000 above the poverty line, 50% higher health gains compared to White children below the poverty line, and 159% higher than White children above the poverty line. We also provide general methodological insights for quantifying the environmental justice impacts of regulatory policies. We demonstrate why using race and poverty status-based prevalence rates is critical for understanding the distribution of health improvements and evaluating whether policies contribute to environmental justice goals.

Review articles

Sophie Glover et al 2024 Environ. Res.: Health 2 032001

Urban green and blue spaces (UGBSs) have been found to have health-enhancing properties (e.g. promotion of physical activity, improved social connectedness, and stress reduction). We examined the associations between UGBSs and cognitive function and aimed to identify any mechanistic pathways involving UGBSs and cognitive function. The initial search of four databases (MEDLINE, Embase, PSYCHInfo, and Web of Science) yielded 4838 studies when duplicates were removed to undergo abstract screening. Following abstract and full text screening, the included studies were classified as 'observational' (proximity to UGBSs, n = 28/35) or 'interventional' ( n = 7/35). Of the included studies, 71.4% ( n = 24/28) of 'observational' studies and 57.1% ( n = 4/7) of 'interventional' studies found positive associations indicating that UGBSs are beneficial for cognitive function (i.e. enhance cognitive function, lower risk of cognitive impairment, or protect cognitive function). Overall, 71.4% ( n = 20/35) of studies included within this review were considered to have a medium risk of bias. Current studies have identified relationships between UGBSs and cognitive function; however, further work is required globally to broaden our understanding and provide a reliable evidence base. Current literature has elucidated numerous mechanistic pathways by which UGBSs have the capacity to operate, including attention restoration theory and stress reduction theory. Advancing the evidence for the mechanistic pathways between UGBSs and cognitive function is required. This may advise future UGBS policies to improve the health and well-being of both the environment and the globally ageing population.

Mayank Gangwar et al 2024 Environ. Res.: Health 2 012001

Indoor air quality (IAQ) in schools has received attention over the past decades but still lacks specific standards and regulations. This study aimed to review the impact of bioaerosol activity in indoor environments on acute respiratory diseases and explore whether carbon dioxide can be used as an indicator of bioaerosol and respiratory diseases in indoor environments in K-12 school systems. Findings suggest a lack of a consensual approach to evaluate bioaerosols impacting IAQ in indoor infrastructures, particularly in school environments; an elevated CO 2 concentration inside the school classrooms was not uncommon, and the evidence of unsatisfactory and degraded IAQ (surpassing ASHRAE standards) at public schools in rural and urban settings in one of the North Central County, Florida. It was found that CO 2 levels can be associated with bioaerosol activity, and sufficient ventilation within the space substantially reduces the airborne time of respiratory droplets and CO 2 levels. CO 2 monitoring can act as an effective, low-cost alternative to surveying or detecting the prevalence of respiratory diseases, which may hold strength through establishing critical CO 2 thresholds and, thereafter associating it with the infectious doses of pathogen activity.

J V F Coumans and S Al Jaaidi 2023 Environ. Res.: Health 1 032002

Exposure to air pollution (AP) is inevitable in daily life and an increasing number of epidemiological studies have reported that exposure to ambient particulate matter (PM) is associated with adverse health outcomes. Intrauterine, childhood, and adolescence are vulnerable periods, during which PM exposure can cause molecular changes, potentially leading to changes in metabolism and development. PM-induced oxidative stress is the underlying mechanism. Biomarkers can be used as illustrative measures of PM exposure to facilitate the assessment of potential health effects and provide a better understanding of the underlying mechanisms. The purpose of this scoping review is to report -OMICS biomarkers found in body fluids that are primarily related to oxidative stress and are already used to evaluate ambient AP exposure, as well as to identify knowledge gaps. Web of Science, PubMed, and Scopus databases were independently searched for all studies published between January 2013 and December 2022 that reported on -OMICS signature changes during pregnancy, childhood, and adolescence. Of the initial 757 articles, 36 met our inclusion criteria and reported on genomic, epigenomic, transcriptomic, proteomic, lipidomic, and metabolomic biomarkers. The findings of this scoping review indicate that exposure to various ambient pollutants in early life can cause oxidative stress. Integrating biomarkers from top-down -OMICS studies in an epidemiological context may provide a clear picture of the biomarker selection process to establish a causal relationship between PM exposure and disease pathogenesis. This knowledge could lead to the conceptualization and subsequent development of novel preventative strategies.

Kathleen A Clark and Mary Sheehan 2023 Environ. Res.: Health 1 022002

The emergence and global spread of the COVID-19 pandemic in 2020 converged with wildfire seasons of unprecedented extent. These co-occurring crises brought the potential for amplified health impacts. A systematized literature review was conducted to identify the health impacts from co-exposure to wildfires and the COVID-19 pandemic. A search of PubMed and Scopus identified 373 distinct references which were screened according to predetermined criteria. A total of 22 peer-reviewed publications were included in the final analysis. Studies were located in Australia and the western United States, with a single study in the Amazonian region of Brazil. The studies identified focused primarily on the impact of wildfire smoke exposure on COVID-19 infection and mortality, and the impact of exposure to both crises on mental health. The collective evidence shows that wildfire exposure within the context of the pandemic exacerbated COVID-19 infection and mortality as well as various adverse mental health effects. Additional research is needed in more diverse contexts and with individual-level data. Findings highlight the need for public health preparedness to anticipate overlapping, related crises and to advance climate change mitigation to protect public health.

Accepted manuscripts

Reed et al 

Heat is the primary cause of weather-related mortality in the United States. The 2021 Northwest Heat Dome highlighted this susceptibility. In Washington State, 159 excess deaths were attributed to the 7-day period of unprecedented extreme heat between June 26th and July 2nd. This impact was felt even in some of the more acclimatized parts of the state, like Spokane County, where 19 heat-related deaths were reported. As climate change increases the frequency, duration, and intensity of extreme heat events, creating and sustaining heat-resilient communities has become an urgent public health priority. On 6 June 2023, Gonzaga University, in partnership with the University of Washington, hosted the Spokane Extreme Heat Risk Intervention Stakeholder Synthesis Symposium. The goals of the symposium were to debrief from recent heat events, identify extreme heat risk reduction interventions used in the region, and characterize remaining practice-relevant research priorities. The symposium convened 45 stakeholders including representatives from local and state agencies, academia, and community-based and Tribal organizations. Symposium participants engaged in small group discussions using the World Café MethodTM. Notes from each discussion were coded using a content analysis approach. Symposium participants identified strengths, barriers to heat resilience, and solutions to reduce risk throughout the Spokane community. We present these findings by practice topic, including risk communication, intervention, collaboration, policy, and research. Additionally, we utilize the Socio-Ecological Model as a conceptual framework to illustrate the complex interplay of factors that govern an individual's experience of, and ability to respond to, extreme heat events. Given extreme heat's impact on global public health, the methods used to increase community resilience in Spokane, WA, USA could be used by other communities worldwide to increase their own heat-resilience.

Haggerty et al 

Human-induced climate change is leading to increased extreme weather events, such as the heat dome that occurred in Multnomah County, OR, in June 2021. Certain groups are at increased risk from excessive heat events, such as the very young and very old, persons without stable housing, and persons with certain health comorbidities. Our review of three data sources (deaths, hospitalizations, and emergency department visits) showed large increases in all three measures in the summer of 2021. Further, two-thirds of identified heat deaths occurred in or near neighborhoods that ranked among the most vulnerable to extreme heat. Despite thoughtful planning, a recently updated heat response plan, and an unprecedented mobilization of resources, we documented severe health impacts due to this heat event. We recommend that local health jurisdictions and emergency responders increase readiness for such events by interrogating existing plans and tailoring them not to a paradoxical "average extreme" event, but to a worst case scenario.&#xD;

Yang et al 

Growing evidence from ecological studies suggests that chronic exposure to standard air pollutants (PM2.5, NO2, and ozone) exacerbates risks of COVID-19 incidence and mortality. This study assessed the associations between an expanded list of air pollutants and COVID-19 incidence and mortality in Los Angeles. Annual mean exposure to air pollutants in 2019  including PM0.1 mass, PM2.5 mass, PM2.5 elemental carbon (EC), PM2.5 tracer from mobile sources, NO2, and ozone  were estimated at the ZIP code level in residential areas throughout Los Angeles. Negative binomial models and a spatial model were used to explore associations between health outcomes and exposures in single pollutant and multi-pollutant models. Exposure to PM0.1 mass, ozone, NO2, and PM2.5 EC were identified as risk factors for COVID-19 incidence and mortality. The results also suggest that PM2.5 and NO2 together may have synergistic effects on harmful COVID-19 outcomes. The study provides localized insights into the spatial and temporal associations between species-specific air pollutants and COVID-19 outcomes, highlighting the potential for policy recommendations to mitigate specific aspects of air pollution to protect public health.

Wu et al 

Background We aimed to evaluate whether the association between long-term temperature variability (TV) and CCVDs was affected by famine exposure in different age stages. &#xD;Methods We used data from the fourth national Urban and Rural Elderly Population survey (2015). Participants were categorized into six groups based on their age at famine exposure (famine exposure under age 5, between ages 5 and 18, and during adulthood) and the severity (severely affected areas versus mildly affected areas) of the Great Chinese Famine (1959-1961) in their province of residence. Mixed-effects logistic regression model was used to quantify the association between long-term TV and the prevalence of CCVDs across six famine-exposed groups.&#xD;Findings A total of 222,179 participants were included. In severely affected areas, the odds ratio (OR) of CCVDs associated with per 1°C increase in 5-year average TV were 1.07 (95% confidence interval [CI]: 1.02, 1.13) for those exposed to famine during adulthood, 1.28 (95% CI: 1.17, 1.40) under the age of 5 years. Urban residence, higher education, increased household income, and more frequent physical activity could mitigate the association between TV and CCVDs, particularly among those exposed to severe famine before the age of 5.&#xD;Conclusion Individuals exposed to famine before the age of 5 are more susceptible to TV-related CCVDs compared to those exposed during adulthood. Our findings highlight the importance of early-life nutrition in lowering susceptibility to CCVDs later in life.

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• 2022-present Environmental Research: Health doi: 10.1088/issn.2752-5309 Online ISSN: 2752-5309

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Environmental Factor

Your online source for niehs news, september 2024, researchers chart a path forward for report back.

NIH kicked off program aimed at studying how to responsibly report back research results to environmental health study participants.

By Marla Broadfoot

In environmental health, "report back" refers to the process of reporting research findings back to the individuals and communities involved in a study. This practice is crucial for fostering transparency, building trust, and promoting actionable change. However, debate around how to ethically report back continues to evolve as the research community shifts to engage study participants as full and equal partners.

On July 26, NIEHS, in partnership with the National Institutes of Health (NIH) Office of Science Policy and the National Human Genome Research Institute (NHGRI), hosted a kickoff meeting for recipients of NIH grants focused on charting a responsible path forward for report back. Researchers from across the country presented eight different awarded projects aimed at informing and developing guidelines, educational resources, and community engagement approaches for effective communication of research results.

“Report back is complicated, and there are lots of different variables that have to be considered in our studies,” said NIEHS Director Rick Woychik, Ph.D. “I’m encouraged that we have a diversified portfolio of research strategies to address these complexities so that we can move forward to get the job done.”

Right to know

Recent research indicates that study participants want to receive their environmental research results, even if the implications for disease risk or health implications are still uncertain. A 2018 report by the National Academies of Sciences, Engineering, and Medicine (NASEM) considered the various issues surrounding report back and provided some early guidance for researchers.

“This report stated in no uncertain terms that report back should be the norm when possible going forward,” said NIEHS Health Scientist Administrator Kimberly McAllister, Ph.D.

In other words, people have the “right to know” the information generated by their research participation. The new grant opportunity, which is a partnership between NIEHS, the NIH Office of Science Policy, the All of Us Research Program, and NHGRI, aims to develop tools and approaches for report back and guidance for addressing the ethical, legal, and social challenges that are part of the process.

“There's a lot of concerns about stigma, discrimination, and privacy risks associated with report back, and this is especially of concern for communities that may be carrying the heaviest burden of chemical exposures,” said McAllister.

Right to design

One project funded by the new grant opportunity is exploring how to report back results on both social determinants of health and environmental exposures — such as arsenic, lead, and cadmium levels in soil and dust — in rural and urban communities that are disproportionately affected by pollution.

“One of the key bioethical questions guiding this work is how do we address technical elitism,” asked Mónica Ramírez-Andreotta, Ph.D. , who leads the project from the University of Arizona.

Ramírez-Andreotta has been using an equity-centered community design approach to identify the factors that influence preferred report back strategies.

“The rationale behind this is extending the ‘right to know’ to the ‘right to design’ and introducing democracy-based values into the report back process,” she said.

Right to understand

Experience shows that participants can benefit from report back and concerns about harm have been overstated, according to the 2018 NASEM report. However, researchers still expressed the desire to carefully navigate specific situations to make sure that report back does not cause harm, citing unintended consequences such as declining property values.

Some also voiced the need for trained environmental counselors, analogous to genetic counselors, who can help participants make sense of their research results. Others shared efforts to forge bidirectional communication between researchers and participants, to move the field from the “right to know” to the “right to understand.”

“These studies create opportunities to expand environmental health literacy about the multifactorial causes of disease in a way that empowers communities and individuals to take action,” said Julia Brody, Ph.D. , from the Silent Spring Institute.

Reporting back

Liam O’Fallon , who directs the NIEHS Partnerships for Environmental Public Health, said that plans are underway to convene the group again within the next six months to identify the logical next steps for advancing the specific aims of each of the projects as well as the broader objectives of the overall program.

“Today, I’ve seen many connections forming in various areas, whether it's environmental health literacy scales and measures, hubs and portals for sharing our lessons learned, or the products, knowledge, and frameworks we need to report back effectively,” he said. “With all of us coming together, I think we are going be able to do something pretty spectacular.”

Citation : Creative Reaction Lab [Internet]. 2018. Equity Centered Community Design Field Guide. Available from: https://crxlab.org/our-approach .

(Marla Broadfoot, Ph.D., is a contract writer for the NIEHS Office of Communications and Public Liaison.)

This new grant opportunity will provide a total of more than $4 million in funding over the next four years to support studies on responsibly reporting back environmental health and non-genomic research results . The following researchers presented overviews of their projects at the kickoff meeting.

• Best practices to return results about pesticide exposures in family child care homes (Abbey Alkon, Ph.D., University of California, San Francisco).
• From the cell to the street: Personalized report-back in large cohort studies with multi-level measurements (Julia Brody, Ph.D., Silent Spring Institute).
• Collaborative development of ethical report-back guidelines for household exposure research (Katrina Korfmacher, Ph.D., University of Rochester Medical Center).
• Engaging community Members to Plan for dissemination Of Wastewater Epidemiology Results: the EMPOWER study (Amy McGuire, J.D., Ph.D., Baylor College of Medicine).
• Disentangling the role of culture, life stage, and information design to facilitate equity in data report back (Mónica Ramírez-Andreotta, Ph.D., University of Arizona).
• Translating Research to Action & Knowledge (TRAK) Portal: a web-based platform for report-back of research results (Diana Rohlman, Ph.D., Oregon State University).
• Evaluation of report-back strategies for long-term and short-term exposure information in rural tribal populations (Scott Collingwood, Ph.D., University of Utah School of Medicine).
• Reframing personal and community report back of consumer products by centering intersectionality (Ami Zota, Sc.D., Columbia University Mailman School of Public Health).

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• Environmental Scan

2023 Environmental Scan of Current and Emerging Public Health Priorities

December 04, 2023

ASTHO’s annual Environmental Scan of Current and Emerging Public Health Priorities (referred to simply as “the Scan” throughout this report) tracks U.S. public health concerns and trends. Through qualitative analyses of select health agency materials and health official feedback, the Scan identifies state, territorial, and freely associated state health agencies’ (S/THAs) top current and emerging priorities across public health programs, infrastructure, and health equity domains, as well as S/THAS’ strategies to address them.

Current State Public Health Program and Service Priorities

Findings in this section are based on an analysis of 32 state health improvement plans (SHIPs), 32 state health agency (SHA) strategic plans, and 32 sets of results from a survey of state health officials (SHOs) conducted between March-July 2023. The included documents were active within a defined period (e.g., 2020 – 2025) or, in the absence of a defined active period, created in or after 2019 by the jurisdictional health agency. ASTHO administered the 2023 Environmental Scan survey to SHOs between April and June 2023. In total, 42 states and Washington, D.C. have at least one plan included in the findings for this section of the report.

• Maternal, child, and family health is a priority area in 60% of states with a SHIP and/or strategic plan included in the Scan and was listed as a top-three current public health program and service priority area by 84% of SHOs who responded to the Environmental Scan Survey.
• Youth and adolescent physical and mental well-being is a focus issue in 42% of SHIPs and strategic plans.
• Early childhood development and health promotion is a focus issue in 40% of plans.
• Prenatal and perinatal care is a focus issue in 38% of plans.
• Maternal and infant mortality is a focus issue in 36% of plans.
• Behavioral health and substance use is a priority area in 63% of states with a SHIP and/or strategic plan included in the Scan and was listed as a top-three current public health program and service priority area by 69% of SHOs who responded to the Environmental Scan Survey.
• Mental health is a focus issue in 44% of SHIPs and strategic plans; suicide prevention, a related issue, is a focus in 30% of plans.
• Substance misuse prevention and harm reduction is a focus in 42% of plans; substance use harm-reduction, a related issue, is a focus in 34% of plans.
• Treatment and recovery services is a focus issue in 39% of plans.
• Opioid use is a focus issue in 23% of plans.
• Access to and linkage with care is a priority area in 81% of states with a SHIP and/or strategic plan included in the Scan and was listed as a top-three current public health program and service priority area by 38% of SHOs who responded to the Environmental Scan Survey.
• Primary and preventive care is a focus issue in 47% of SHIPs and strategic plans.
• Health insurance coverage and care affordability is a focus issue in 39% of plans; economic barriers to healthcare access, a related issue, is a focus issue in 27% of plans.
• Quality of care is a focus issue in 38% of plans; inequities in healthcare outcomes, a related issue, is a focus in 36% of plans.
• Coordination and continuity of care is a focus issue in 38% of plans.
• Communicable disease control is a priority area in 28% of states with a SHIP and/or strategic plan included in the Scan and was listed as a top-three current public health program and service priority area by 63% of SHOs who responded to the Environmental Scan Survey.
• Immunization and vaccination is a focus issue in 31% of SHIPs and strategic plans.
• Sexually transmitted infections and diseases are focus issues in 16% of plans; HIV and AIDS, related issues, are a focus in 14% of plans.  
• Building capacity for communicable disease laboratory testing and monitoring is a focus issue in 17% of plans.
• Chronic disease prevention is a priority area in 65% of states with a SHIP and/or strategic plan included in the Scan and was listed as a top-three current public health program and service priority area by 16% of SHOs who responded to the Environmental Scan Survey.
• Nutrition, physical activity, and other modifiable personal health behaviors are focus issues in 50% of SHIPs and strategic plans.
• Tobacco and vape use is a focus issue in 41% of plans.
• Healthy weight (obesity prevention) is a focus issue in 39% of plans.

Current Island Jurisdiction Public Health Program and Service Priorities

Findings in this section are based on an analysis of information expressed by territorial and freely associated state health officials (denoted as “THOs” for the purposes of this report) in ASTHO surveys (e.g., the 2022 ASTHO Profile survey and 2023 ASTHO Environmental Scan survey), forums (e.g., the Insular Affairs Committee to the ASTHO Board), individual conversations between health officials and ASTHO staff, and current strategic documents as available from the Atlantic island jurisdictions and the Republic of the Marshall Islands. ASTHO administered the 2022 Profile Survey between April and December 2022 and the THO Environmental Scan survey between April and June 2023, garnering completed responses from THOs representing six of the eight island territories and freely associated states (a 75% response rate) for both.

• Communicable disease control was listed as a top-three current public health program and service priority area by four THOs (66%) who responded to the Environmental Scan Survey and was listed as a top-five population health priority by all six THOs (100%) who completed the 2022 ASTHO Profile Survey. Focus issues in this area include vaccine-preventable diseases, including COVID-19; regional lab testing services; dengue and other tropical diseases; tuberculosis (TB), including multi-drug resistant TB; sexually transmitted diseases, including HIV; and safe drinking water.
• Access to and linkage with care was listed as a top-three current public health program and service priority area by four THOs (66%) who responded to the Environmental Scan Survey and a top-five population health priority by all six THOs (100%) who completed the 2022 ASTHO Profile Survey. Focus issues in this area include telehealth; mental and behavioral health service options; substance use prevention and treatment; maternal, infant, child, and older adult healthcare; community-based public health and partnerships; health equity; and access to care supports for underserved communities.
• Chronic disease prevention (and treatment) was listed as a top-three current public health program and service priority area by one THO (17%) who responded to the Environmental Scan Survey and was a top-five population health priority for five THOs (83%) who completed the 2022 ASTHO Profile Survey. Focus issues in this area include prevention and treatment for cancer, respiratory disease, heart disease, stroke, and diabetes; risk factors for chronic disease; and nutrition and physical activity.

Current State Public Health Infrastructure and Capacity-Building Priorities

Findings in this section are based on an analysis of the same materials used to identify SHAs’ program and service priorities above.

• Workforce development is a priority area in 51% of states with a SHIP and/or strategic plan included in the Scan and was listed as a top-three current public health infrastructure and capacity-building priority area by 75% of SHOs who responded to the Environmental Scan Survey.
• Training and education is a focus issue in 52% of SHIPs and strategic plans.
• Recruitment and retention is a focus issue in 39% of plans.
• (Re-)Building clinical and laboratory workforce capacity is a focus issue in 38% of plans.
• Organizational competencies include functions related to organizational finances, human resources, culture, leadership, IT systems, and general capacity to carry out core public health work. They are a priority area in 63% of states with a SHIP and/or strategic plan included in the Scan and this category was listed as a top-three current public health infrastructure and capacity-building priority area by 38% of SHOs who responded to the Environmental Scan Survey.
• Funding strategies and grant writing are a focus issues in 41% of SHIPs and strategic plans.
• Funding and resource management are focus issues in 41% of plans.
• Organizational culture and leadership are focus issues in 28% of plans.
• Accountability, performance management, and quality improvement is a priority area in 67% of states with a SHIP and/or strategic plan included in the Scan and was listed as a top-three current public health infrastructure and capacity-building priority area by 28% of SHOs who responded to the Environmental Scan Survey.
• Quality improvement and accreditation are focus issues in 36% of SHIPs and strategic plans.
• Performance measurement and evaluation is a focus issue in 34% of plans.
• Performance improvement planning is a focus issue in 27% of plans.
• Data modernization and informatics is a priority area in 33% of states with a SHIP and/or strategic plan included in the Scan and was listed as a top-three current public health infrastructure and capacity-building priority area by 59% of SHOs who responded to the Environmental Scan Survey.
• Public health data sharing and coordination is a focus issue in 34% of SHIPs and strategic plans.
• Public health data standards and interoperability are focus issues in 25% of plans.
• Building organizational capacity for data-driven decision-making is a focus issue in 19% of plans.
• Organizational equity is a priority area in 49% of states with a SHIP and/or strategic plan included in the Scan and was listed as a top-three current public health infrastructure and capacity-building priority area by 31% of SHOs who responded to the Environmental Scan Survey.
• Organizational health literacy is a focus issue in 42% of SHIPs and strategic plans and 47% of states’ health equity plans or goals.
• Equity-centered processes and policies is a focus issue in 25% of SHIPs and 58% of states’ health equity plans or goals.
• Equity-focused public health interventions and programs is a focus in 31% of SHIPs and 33% of states’ health equity plans or goals.  
• Diversity, equity, inclusion, accessibility, and belonging are focus issues in 23% of SHIPs and strategic plans and 36% of states’ health equity plans or goals.

Current Island Jurisdiction Public Health Infrastructure Priorities

Findings in this section are based on an analysis of the same materials used to identify THAs’ program and service priorities above.

• Organizational competencies , including performance management and quality improvement, were listed as top-three current public health infrastructure and capacity-building priority areas by four THOs (66%) who responded to the Environmental Scan Survey and four THOs (66%) who responded to the 2022 ASTHO Profile Survey. Focus issues in this area include financial infrastructure; financial sustainability of staff, structures, and service; business processes, including procurement, recruitment, and grants management; performance management and quality improvement; policy development; and public health governance structures.
• Emergency preparedness and response was listed as a top-three current public health infrastructure and capacity-building priority area by four THOs (66%) who responded to the Environmental Scan Survey and two THOs (33%) who responded to the 2022 ASTHO Profile Survey. Focus issues in this area include emergency preparedness response and recovery networks and lessening the impact of climate change.
• Data modernization and informatics was listed as a top-three current public health infrastructure and capacity-building priority area by three THOs (50%) who responded to the Environmental Scan Survey and three THOs (50%) who responded to the 2022 ASTHO Profile Survey. Focus issues in this area include data collection, analysis, and clinical and applied research; data-driven decision-making; data representation in federal datasets; interoperability across government systems; and the modernization of electronic health records and telehealth systems.
• Workforce development was listed as a top-three current public health infrastructure and capacity-building priority area by the one THO (17%) who responded to the Environmental Scan Survey and the four THOs (66%) who responded to the 2022 ASTHO Profile Survey. Focus issues in this area include recruitment and retention, local academic pipelines and training opportunities; staff compensation; and staff salary gaps.

Health Official Survey: Recent Impacts on Public Health Priorities

We asked state and territorial health officials THOs, “ In the past 6 months, what events or trends have impacted your agency’s priorities, and how? ”  The events and trends most frequently mentioned across 32 SHO and 6 THO responses include:

• Newly passed laws and legislation.
• Ending of the COVID-19 public health emergency.
• Health workforce shortages.
• New infectious diseases and communicable disease outbreaks.
• Reduced public confidence in vaccines.
• Environmental trends and climate-related events.
• Ongoing mental health, opioid, and maternal health crises.
• New federal funding to support health agency work in specific areas (such as health equity and public health infrastructure).

Health Official Survey: Emerging Public Health Priorities

We asked S/THOs, “ In the next 6 months, what new or emerging issues do you anticipate will become bigger priorities for state health agency leaders ?” The emerging priorities most frequently mentioned across 32 SHO and six THO responses include:

Emerging Public Health Program and Service Priorities

• Mental and behavioral health.
• Medical autonomy and access to care issues.
• Environmental issues and climate change.
• Emerging or resurging infectious diseases.

Emerging Public Health Infrastructure and Capacity-Building Priorities

• Public health data modernization.
• Combatting misinformation.
• Emergency and extreme weather preparedness.

Health Official Survey: Strategies to Advance Health Equity

We asked S/THOs, “ In the past 6 months, which 3 key strategies or initiatives has your agency engaged in to advance health equity? ” The most frequently mentioned strategies across 32 SHO and six THO responses include:

• Developing workforces and organizations to increase capacity for health equity work.
• Promoting internal organizational literacy in health equity topics.
• Offering staff education and training on topics related to diversity, equity, inclusion, accessibility, and belonging.
• Increasing workforce diversity.
• Engaging and supporting communities to improve. health outcomes.
• Bringing more high-value, low-cost health services to communities.
• Emphasizing equity in all policies and advocacy work.
• Improving and utilizing data to better understand and address health inequities.
• Focusing on the equitable distribution of resources.

Cross-Cutting State Health Equity Focus Areas and Key Strategies

While health equity is a core focus across all state public health policy and practice, the Scan highlights three key cross-cutting health equity focus areas: personal health literacy, the social determinants of health, and access to and linkage with care. Findings in this section are based on an analysis of 32 SHIPs, 32 SHA strategic plans, 36 SHA health equity plans or list of health equity goals, and 32 SHO survey responses. In total, 48 states and Washington, D.C. have at least one plan or goal statement included in this section of the report’s findings.

Cross-Cutting State Health Equity Focus Area: Personal Health Literacy

Personal health literacy is a priority area in 60% of states and 39% of all plans included in the Scan, and was discussed in the context of understanding or addressing population health inequities in 53% of all plans.

• Culturally and linguistically appropriate health information, education, and services are focus issues in 52% of all SHA plans.
• Health and safety information that is accurate, accessible, and actionable is a focus issue in 37% of plans.
• Healthcare system changes to improve personal health literacy is a focus issue in 21% of plans.

Cross-Cutting State Health Equity Focus Area: Social Determinants of Health

Social determinants of health (SDOH) is a priority area in 72% of states and 59% of all SHA plans included in the Scan. This was discussed in the context of understanding or addressing population health inequities in 47% of all plans.

• Community capacity-building and resilience to health threats is a focus issue in 38% of all SHA plans.
• Service environment is a focus issue in 38% of plans.  
• Social and community connectivity is a focus issue in 35% of plans.  
• Built and natural environment is a focus issue in 31% of plans; environmental justice, a related issue, is a focus in 9% of plans.

Cross-Cutting State Health Equity Focus Area: Access to and Linkage with Care

Access to and linkage with care, a priority area in 70% of states and 48% of all SHA plans, was discussed in the context of understanding or addressing population health inequities in 44% of all plans, more than any other public health program and service area. The Scan found that the population groups most disproportionately impacted by the following inequities in access to the following services include BIPOC communities, rural communities, people experiencing poverty, people living with and disabilities, and LGBTQI+ communities.

• Access to maternal and infant care: ”Maternal, Child, and Family Health” was discussed in the context of understanding or addressing population health inequities in 30% of all SHA plans, ”prenatal and perinatal care” was discussed in 13% of plans, “infant mortality” was discussed in 13% of plans, and "maternal mortality” was discussed in 10% of plans.
• Access to mental health and substance use care: “behavioral health and substance use” was discussed in the context of understanding or addressing population health inequities in 22% of all SHA plans. “mental health” was discussed in 12% of plans, “substance use harm reduction” was discussed in 10% of plans, and “treatment and recovery services” was discussed in 9% of plans.
• Access to chronic disease prevention and management services: “chronic disease prevention” was discussed in the context of understanding or addressing population health inequities in 21% of all SHA plans. “Healthy weight (obesity prevention)” was discussed in 9% of plans, and “nutrition, physical activity, and other modifiable personal health behaviors’ was discussed in 9% of plans.
• Access to health insurance and affordable care: “Health insurance coverage” was discussed in the context of understanding or addressing population health inequities in 21% of all SHA plans and “affordability of care” was discussed in 16% of plans.
• Access to care in rural and geographically isolated communities: “Rural or geographically isolated communities” was discussed in the context of understanding or addressing population health inequities in 13% of all SHA plans.

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• Published: 13 September 2024

Differential effects of environmental exposures on clinically relevant endophenotypes between sexes

• Tomás González Zarzar 1 , 2 ,
• Nicole E. Palmiero 3 ,
• Dokyoon Kim 4 ,
• Li Shen 4 &
• Molly A. Hall 3  

Scientific Reports volume  14 , Article number:  21453 ( 2024 ) Cite this article

Metrics details

• Biological techniques
• Medical research
• Risk factors

Sex and gender differences play a crucial role in health and disease outcomes. This study used data from the National Health and Nutrition Examination Survey to explore how environmental exposures affect health-related traits differently in males and females. We utilized a sex-stratified phenomic environment-wide association study (PheEWAS), which allowed the identification of associations across a wide range of phenotypes and environmental exposures. We examined associations between 272 environmental exposures, including smoking-related exposures such as cotinine levels and smoking habits, and 58 clinically relevant blood phenotypes, such as serum albumin and homocysteine levels. Our analysis identified 119 sex-specific associations. For example, smoking-related exposures had a stronger impact on increasing homocysteine, hemoglobin, and hematocrit levels in females while reducing serum albumin and bilirubin levels and increasing c-reactive protein levels more significantly in males. These findings suggest mechanisms by which smoking exposure may pose higher cardiovascular risks and greater induced hypoxia for women, and greater inflammatory and immune responses in men. The results highlight the importance of considering sex differences in biomedical research. Understanding these differences can help develop more personalized and effective health interventions and improve clinical outcomes for both men and women.

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Introduction.

Sex and gender differences are crucial in health and disease outcomes 1 . These differences in disease prevalence, risk factors, progression, and treatment response underscore the importance of considering sex and gender differences in biomedical research. For instance, females are at greater risk of developing immune diseases, while males have a higher risk of non-reproductive cancers 2 . Additionally, cardiovascular diseases have different pathologic mechanisms across sexes 3 , and females are more susceptible to chronic obstructive pulmonary disease (COPD) 4 .

While some sex and gender differences are well-documented across various health outcomes, significant gaps remain in our understanding of how environmental factors contribute to these disparities. This gap is particularly evident in research on environmental influences on health, which has yet to explore how these exposures differentially affect males and females extensively 5 . For example, sex differences in response to environmental exposures, such as those observed in occupational asthma and smoking-related lung function decline, highlight the need for more comprehensive studies in this area 6 , 7 , 8 , 9 , 10 .

Some sex differences, such as the difference in occupational asthma, might be explained by different degrees of environmental exposure between sexes, which might be attributed to gender differences 6 . In contrast, other differences, such as mortality and lung function differences between male and female smokers, are due to differential effects of the same environmental exposure 10 . Differential biological pathways, interactions with sex hormones, or genetic and epigenetic mechanisms might mediate the latter type of differences 11 .

Sex refers to the biological attributes that distinguish male and female organisms, including chromosomes, hormone levels, and reproductive anatomy. These biological differences are typically categorized as male or female but include intersex. Gender, on the other hand, refers to the roles, behaviors, activities, expectations, and norms that cultures and societies consider appropriate for men, women, and gender-diverse people. It is crucial to understand the distinction and the potential for interaction between sex and gender in biomedical research, as both can influence health outcomes and provide different interpretative scopes 1 , 12 .

Adopting research methodologies that capture the complex interplay between sex, environmental exposures, and health outcomes is essential to addressing these gaps. Genome-wide association studies (GWAS) and phenome-wide association studies (PheWAS) have been pivotal in identifying genetic and phenotypic associations, respectively, across diverse populations 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 . Environment-wide association studies (EWAS) have expanded on these methodologies and explored the associations between numerous environmental exposures and health outcomes 21 , 22 , 23 , 24 , 25 . While evaluating associations between multiple exposures and a single phenotype in EWAS has proven valuable, considering phenotypes in isolation can hinder the ability to detect exposures with cross-phenotype associations or associations between a single environmental exposure and multiple phenotypes.

Understanding the sex-specific effects of environmental exposures is crucial for assessing environmental risks, guiding therapeutic recommendations, and generating new biological hypotheses. To address this knowledge gap, we conducted a sex-stratified phenomic environment-wide association study (PheEWAS) to investigate the associations between environmental exposures and clinically relevant phenotypes. PheEWAS is a hypothesis-free approach that tests for significant associations between multiple environmental exposures and multiple phenotypes. By examining these associations across a broad range of phenotypes, this study aims to uncover sex-specific mechanisms that could inform precision health strategies and improve clinical outcomes. Utilizing data from the National Health and Nutrition Examination Survey (NHANES), we evaluated 18,937 participants across 58 phenotypes and 272 environmental exposures. By classifying sex-different exposure-phenotype associations into pure, quantitative, and qualitative categories 26 , we aim to elucidate the mechanisms underlying these associations and provide insights that could inform precision health approaches. Our results suggest promising avenues to explore exposures that pose differential risks to the sexes, elucidate biological pathways with significant sex-based differences, and open the road to more personalized therapeutics.

Materials and methods

Nhanes data sets.

This study utilized data from NHANES to identify sex-specific exposure-phenotype associations. NHANES is a program of studies that uses data from physical examinations and interviews to assess the health and nutritional status of adults and children in the U.S. The physical examination includes medical, dental, and physiological measurements and laboratory tests. The interview includes demographic, socioeconomic, dietary, and health-related questions.

We analyzed 1191 variables and 41,474 participants from four survey periods (1999–2000, 2001–2002, 2003–2004, and 2005–2006), 27 , 28 , using a discovery (1999–2000 and 2001–2002) and replication (2003–2004 and 2005–2006) design 29 , 30 , split by sex into four cohorts: discovery females ( df ), discovery males ( dm ), replication females ( rf ), and replication males ( rm ).

To select relevant phenotypes and exposures, we focused on 84 routine clinical measurements, including blood and urine biomarkers and hormones, and 739 exposures related to health outcomes, such as tobacco and alcohol use, heavy metals, and volatile compounds. PheEWAS, as a hypothesis-generating approach, relies on a wide selection of exposures and phenotypes, only restricted to retaining high-quality variables. Data cleaning procedures described below ensured high-quality phenotypes and exposures.

We applied survey weights according to NHANES guidelines, using 4-year weights for the discovery cohorts and adjusted 2-year weights for the replication cohorts. We excluded three phenotypes and 116 exposures lacking survey weight data. Data cleaning, QC, and analyses were done using CLARITE software 30 . All analytical steps and code are available in Zenodo (DOI: 10.5281/zenodo.6483503 ), along with replication instructions and package details.

Data quality control

The QC process was conducted independently in each of the four cohorts, but if a variable was removed in one cohort, it was removed from all. Participants aged 18 and older, with no upper age limit, and complete covariate data were included ( \(N=18{,}937, N_{df}=4724, N_{dm}=4339, N_{rf}=5123, N_{rm}=4751\) ). Low-density lipoprotein values (NHANES code name: LBDLDL) were adjusted by dividing by 0.7 for participants on statins.

Variables were categorized using CLARITE as constant, binary, categorical, and continuous. Constants (single-value variables that were not covariates or phenotypes), variables with only missing data, and continuous variables with less than ten unique values were removed. Filters ensured proper sample sizes and high-quality variables in each cohort. Variables with fewer than 200 non-missing values, binary or categorical variables with fewer than 200 observations per category, and continuous variables with more than 90% of values at zero were excluded. This left 59 phenotypes and 281 exposures.

Continuous variables were log2 transformed and z-score normalized to address skewed distributions while retaining biologically meaningful values. Briefly, transforming raw values into their base 2 logarithms provides a way to produce symmetric distributions and keep easily interpretable values because changes in a one-unit increase in a log2-transformed variable correspond to a doubling of the original value 31 , 32 . On the other hand, z-score normalization makes variables comparable even when measured on different scales or units, allowing comparisons across exposure-phenotype results. Outliers, defined as values three standard deviations from the mean, were treated as missing and re-filtered, removing nine additional exposures. A Pearson correlation was used to detect identical transformed variables, leading to the removal of one phenotype. The final dataset for PheEWAS included eight covariates, 58 phenotypes, and 272 exposures. Summary statistics for all covariates are available in Table  1 .

Statistical methods

Following the preparation and cleaning of the dataset, statistical analyses were conducted to explore the associations between exposures and phenotypes. A sex-stratified PheEWAS was conducted to estimate associations between 58 phenotypes and 272 exposures, adjusting for eight covariates, including age, socioeconomic status (SES), body mass index (BMI), survey year, and four race/ethnicity categories. Analyses were performed separately for each cohort using generalized linear models adjusted for survey weights. A minimum of 200 complete observations were required for a successful regression. Finally, observations were dropped in each regression if they had missing values in the phenotype or exposure or missing survey weight information. An inverse variance meta-analysis was used to generate sex-specific results in the female and male cohorts 26 , 33 .

Sex difference analysis

Sex differences in exposure-phenotype associations were assessed by comparing \(\beta\) values between males and females. Differences were categorized as pure (significant in one sex but not the other), quantitative (significant in both sexes with differing effect sizes), or qualitative (significant in both sexes with opposing effect directions). Two approaches were used to detect sex differences:

Full Evaluation Approach: all possible exposure–phenotype associations were tested for sex differences using the following formula

where \(\beta _{f}\) and \(\beta _{m}\) are the effect sizes in the female and male cohorts, respectively, and \(se_{f}\) and \(se_{m}\) are their standard errors. Significant sex differences were identified using a Bonferroni-corrected \(\alpha _{diff}\) based on M total number of tests, such that \(\alpha _{diff} = \frac{0.05}{M}\) .

Filtering-First Approach: associations significant across both sexes were filtered first using the following formula

Associations with \(p_{overall} < 10^{-5}\) were retained for sex difference testing using formula 1 . A Bonferroni-corrected \(\alpha _{diff}\) was applied based on N number of filtered tests, such that \(\alpha _{diff} = \frac{0.05}{N}\) .

Both approaches were employed to capture different types of sex differences, providing a comprehensive evaluation. Specifically, the full evaluation approach is better suited to detect qualitative sex differences, whereas the filtering-first approach is better suited to detect quantitative and pure sex differences 26 . Differences significant by either approach were classified into pure, quantitative, or qualitative categories.

Age stratification

To assess the robustness of our findings and account for potential confounding effects of hormonal changes across the lifespan, we replicated the analysis by excluding participants 46 years or older. We retained 10,149 participants, with sample sizes across cohorts of \(N_{df}=2650; N_{dm}=2248; N_{rf}=2822; N_{rm}=2429\) . This exclusion criterion removes the influence of age-related hormonal transitions on the observed associations between environmental exposures and health outcomes.

We conducted 15,999 association tests in each of the four NHANES cohorts: discovery females, discovery males, replication females, and replication males. For further details on the sample sizes of each cohort, please refer to the “ Materials and methods ” section. The number of converged tests varied slightly across cohorts because some tests had fewer than 200 complete observations (between 15,470 in the replication males cohort and 15,994 in the discovery females and discovery males cohorts). From the successful tests, 15,466 exposure-phenotype associations converged across all cohorts and were used to estimate sex differences. We identified 119 significant sex-specific associations, of which 49 were classified as pure, 45 as quantitative, and 25 as qualitative.

Among the 58 phenotypes evaluated, 35 showed sex-specific associations with at least one exposure. Serum albumin levels had the highest number of sex-specific associations, with 30 different exposures, including smoking-related exposures (e.g., blood cotinine levels, number of cigarettes smoked daily, and whether anyone smokes in the household), nutrients (e.g., folate, vitamins A, D, and E), supplements (e.g., folic acid, calcium, vitamin C), and heavy metals and volatile compounds. Other phenotypes with notable associations included red cell count and C-reactive protein levels, which had sex-specific associations with heavy metals like cadmium and lead, and volatile compounds such as ethylbenzene and toluene (Figs.  1 ,  2 ).

Miami Plot from PheEWAS results stratified by sex. The Y axis shows the -log of the p-value, and the X axis is sorted by exposure categories. Significant sex differences are highlighted in color, and categorized as pure, quantitative, and qualitative sex differences. Relevant exposure-phenotype associations discussed in the manuscript are annotated.

Of the 272 exposures evaluated, 53 had sex-specific associations with at least one phenotype. Exposures to heavy metals (e.g., lead and cadmium), nutrients (e.g., vitamins A and E, lutein and zeaxanthin), and smoking behaviors were most frequently associated with phenotypes such as serum albumin, C-reactive protein, and red cell count. Lead exposure, for example, was associated with 11 different phenotypes, underscoring its widespread impact on various clinically relevant measurements (Figs.  1 ,  2 ). Supplementary Table 1 shows the complete set of results in more detail.

Circos plot of significant exposure-phenotype associations divided by sex and type of sex difference. In each circos plot, exposures are in the upper section and phenotypes in the lower section of the circle. The presence of a line connecting an exposure and phenotype indicates a significant association. Red lines indicate a negative association and blue lines indicate a positive association. The width of the line indicates the effect size, with greater width indicating a greater absolute effect size.

Pure sex differences

We identified 53 pure sex-specific associations, with a slight bias toward males. In females, exposures in pure associations were primarily heavy metals, food component recall, nutrients, and volatile compounds, associated with phenotypes like red cell count, lymphocyte percent, albumin, HDL cholesterol, and homocysteine. For example, blood levels of the volatile compounds ethylbenzene ( \(\beta _{f}=0.096, \beta _{m}=-0.020, P_{diff}=1.53E-05\) ) and toluene ( \(\beta _{f}=0.115, \beta _{m}=-0.015, P_{diff}=3.91E-06\) ) were both associated with red cell counts in females. In contrast, lead was associated with albumin ( \(\beta _{f}=0.084, \beta _{m}=-0.028, P_{diff}=4.31E-09\) ), creatinine ( \(\beta _{f}=0.076, \beta _{m}=-0.005, P_{diff}=1.96E-06\) ), and sodium levels ( \(\beta _{f}=0.07, \beta _{m}=-0.024, P_{diff}=4.49E-06\) ). In males, exposures in pure associations were often categorized as nutrients, smoking behavior, and supplement use, with albumin showing associations with 17 different exposures (Figs.  2 ,  3 ; Table  2 ).

Nineteen pure associations involved smoking-related exposures. For example, cotinine levels were associated with albumin levels ( \(\beta _{f}=0.005, \beta _{m}=-0.089, P_{diff}=2.36E-13\) ) and osmolality ( \(\beta _{f}=-0.015, \beta _{m}=-0.086, P_{diff}=8.16E-06\) ) in males and with red cell count ( \(\beta _{f}=0.074, \beta _{m}=-0.006, P_{diff}=3.9E-06\) ) in females. Similarly, “Does anyone smoke in home?” was associated with albumin levels ( \(\beta _{f}=-0.020, \beta _{m}=-0.179; P_{diff}=0.1E-06\) ) in males and with HDL cholesterol ( \(\beta _{f}=-0.280, \beta _{m}=-0.051, P_{diff}=3.38E-06\) ) and red cell count ( \(\beta _{f}=0.186, \beta _{m}=0.002, P_{diff}=4.52E-06\) ) in females. Two of the ten survey questions related to smoking behavior were positively associated with homocysteine levels in females. In contrast, seven were associated with albumin and one with C-reactive protein in males (Fig.  3 ).

Forest plot showing the effect sizes and 95% confidence intervals in males and females. Exposures are defined on the left side and phenotypes on the right. Plots are divided into the three sex difference categories of pure, quantitative, and qualitative.

Quantitative sex differences

Forty-five quantitative sex-specific associations were identified, with greater effect sizes observed more frequently in males. Notably, heavy metal exposures like cadmium had greater effect on males on phenotypes like monocyte number ( \(\beta _{f}=0.092, \beta _{m}=0.166, P_{diff}=7.48E-06\) ), segmented neutrophils number ( \(\beta _{f}=0.111, \beta _{m}=0.206, P_{diff}=2.2E-08\) ), C-reactive protein level ( \(\beta _{f}=0.045, \beta _{m}=0.144, P_{diff}=6.01E-09\) ), mean cell hemoglobin level ( \(\beta _{f}=0.047, \beta _{m}=0.135, P_{diff}=1.01E-09\) ), mean cell volume ( \(\beta _{f}=0.057, \beta _{m}=0.145, P_{diff}=1.27E-10\) ), and white blood cell count ( \(\beta _{f}=0.151, \beta _{m}=0.252, P_{diff}=9.7E-10\) ); while in females it had greater effect on red cell count ( \(\beta _{f}=0.127, \beta _{m}=0.027, P_{diff}=6.97E-11\) ). On the other hand, lead exposure had greater effect on females on bone alkaline phosphatase level ( \(\beta _{f}=0.233, \beta _{m}=0.049, P_{diff}=5.87E-14\) ), homocysteine level ( \(\beta _{f}=0.210, \beta _{m}=0.130, P_{diff}=5.17E-06\) ), red cell count ( \(\beta _{f}=0.190, \beta _{m}=0.071, P_{diff}=1.1E-09\) ), and alkaline phosphatase level ( \(\beta _{f}=0.193, \beta _{m}=0.064, P_{diff}=7.9E-12\) ) (Figs.  2 ,  3 ; Table  3 ).

Smoking-related exposures, including cotinine levels, “Does anyone smoke in home?”, and “Current or Past Cigarette Smoker?” had greater positive effects on hematocrit in females. Similarly, associations between current or past cigarette smoking and hemoglobin level ( \(\beta _{f}=0.429, \beta _{m}=0.236, P_{diff}=1.25E-06\) ) and between the average number of cigarettes smoked per day during the past 30 days and homocysteine level ( \(\beta _{f}=0.154, \beta _{m}=0.038, P_{diff}=2.71E-06\) ) had greater effects in females. Conversely, all other quantitative associations between smoking-related exposures and bilirubin level, creatinine level, segmented neutrophils number, mean cell hemoglobin level, and white blood cell count had greater effects in males (Fig.  3 ).

Quantitative associations involving serum albumin, triglyceride, and GGT levels tended to have larger effects in males. For example, the associations between g-tocopherol and GGT level ( \(\beta _{f}=0.066, \beta _{m}=0.129, P_{diff}=2.08E-05\) ), g-tocopherol and triglyceride level ( \(\beta _{f}=0.20, \beta _{m}=0.319, P_{diff}=1.35E-10\) ), retinyl palmitate and triglyceride level ( \(\beta _{f}=0.273, \beta _{m}=0.394, P_{diff}=7.65E-11\) ), vitamin A and albumin level ( \(\beta _{f}=0.145, \beta _{m}=0.258, P_{diff}=8.65E-11\) ), and vitamin E and GGT level ( \(\beta _{f}=0.032, \beta _{m}=0.145, P_{diff}=4.3E-07\) ) had greater effects sizes in males. Conversely, associations with homocysteine and urine albumin tended to have greater effects in females than in males. For example, the associations between iron supplement use and homocysteine level ( \(\beta _{f}=-0.127, \beta _{m}=-0.064, P_{diff}=1.78E-07\) ) and between cesium level in urine and urine albumin level ( \(\beta _{f}=0.504, \beta _{m}=0.362, P_{diff}=2.74E-09\) ) had greater effect sizes in females.

Qualitative sex differences

Twenty-five qualitative sex differences were identified, mostly involving nutrient exposure, food component recall, and heavy metals. Exposures to lead, lutein and zeaxanthin, retinyl palmitate, and vitamin A were associated with more than one phenotype, whereas the phenotypes albumin, C-reactive protein, and lymphocyte percent were associated with more than one exposure. Notably, various folate and iron measurements were negatively associated with albumin levels in females and positively associated in males (Fig.  3 ). Moreover, lead exposure was differentially associated with osmolality ( \(\beta _{f}=0.044, \beta _{m}=-0.061, P_{diff}=5.91E-08\) ), bilirubin levels ( \(\beta _{f}=0.068, \beta _{m}=-0.029, P_{diff}=6.11E-07\) ), and C-reactive protein levels ( \(\beta _{f}=-0.075, \beta _{m}=0.049, P_{diff}=8.48E-10\) ) (Figs.  2 ,  3 ; Table  4 ).

When analyzing participants younger than 46, we identified 107 significant sex-specific associations: 43 were classified as qualitative, 27 as quantitative, and 37 as pure. Supplementary Table 2 contains the complete set of results for the young cohort. We identified 54 exposure-phenotype pairs replicated from the entire cohort, 34 of which showed the same type of sex difference classification, and 20 were classified differently. Notable examples of replicated findings with the same sex difference classification were the effects of cadmium on segmented neutrophils number ( \(\beta _{f}=0.11, \beta _{m}=0.20, P_{diff}=1.18E-05\) ), C-reactive protein ( \(\beta _{f}=0.03, \beta _{m}=0.12, P_{diff}=4.10E-06\) ), mean cell volume ( \(\beta _{f}=0.05, \beta _{m}=0.14, P_{diff}=5.45E-06\) ), and albumin ( \(\beta _{f}=-0.002, \beta _{m}=-0.08, P_{diff}=2.47E-06\) ), and the effect of smoking behavior (number of cigarettes smoked per day now and average number of cigarettes per day during past 30 days) and lead on homocysteine ( \(\beta _{f}=0.21, \beta _{m}=0.03, P_{diff}=3.06E-06; \beta _{f}=0.20, \beta _{m}=0.05, P_{diff}=2.02E-05; \beta _{f}=0.23, \beta _{m}=0.12, P_{diff}=7.22E-06\) ). Albumin also showed consistent results, specifically in its association with lead, cadmium, and smoking behavior (current or past cigarette smoker)( \(\beta _{f}=0.10, \beta _{m}=-0.02, P_{diff}=1.88E-07; \beta _{f}=0.002, \beta _{m}=-0.08, P_{diff}=2.47E-06; \beta _{f}=0.04, \beta _{m}=-0.17, P_{diff}=1.65E-07\) ).

Even though 54 results were replicated in the younger cohort, 20 had different sex difference classifications. Notable examples were the associations of cotinine with red cell count ( \(\beta _{f}=0.053, \beta _{m}=-0.04, P_{diff}=2.28E-05\) ) and albumin ( \(\beta _{f}= 0.03, \beta _{m}=-0.08, P_{diff}=3.38E-10\) ) which were classified as pure sex differences in the entire cohort, but as qualitative in the young cohort. Similarly, the association between smoking behavior (number of days smoked cigarettes during the past 30 days) and albumin ( \(\beta _{f}=0.04, \beta _{m}=-0.10, P_{diff}=1.65E-05\) ) was classified as pure in the entire cohort, but qualitative in the young cohort.

On the other hand, we identified 53 novel exposure-phenotype pairs compared to the entire cohort. Of these, 12 associations were classified as quantitative, 22 as qualitative, and 19 as pure. Notable examples were the association between the FTC nicotine and tar content of the participants’ preferred cigarette brand and smoking behavior (how many years smoked this amount) with homocysteine ( \(\beta _{f}=0.18, \beta _{m}=0.03, P_{diff}=5.44E-06; \beta _{f}=0.18, \beta _{m}=0.03, P_{diff}=2.54E-06\) ), which showed a significant association only in females. Similarly, FTC carbon monoxide content of participants’ preferred cigarette brand, cotinine, and smoking family (does anyone smoke in home?) were positively associated with homocysteine across sexes but with greater effect sizes in females ( \(\beta _{f}=0.18, \beta _{m}=0.04, P_{diff}=1.42E-05; \beta _{f}=0.16, \beta _{m}=0.07, P_{diff}=2.40E-05; \beta _{f}=0.30, \beta _{m}=0.08, P_{diff}=8.17E-07\) ).

We conducted a PheEWAS to identify sex-specific associations between 58 phenotypes and 272 environmental exposures among more than 18,000 NHANES participants. Our study identified environmental exposures with sex-specific effects on several blood phenotypes. Our analysis’s high-throughput and agnostic nature provides avenues for further research into the biological, environmental, and mechanistic aspects of these sex differences. Furthermore, our study demonstrates the utility of using an explicit PheEWAS framework to target potential differences between sexes instead of evaluating sex differences as a complementary analysis.

We identified 119 exposure-phenotype associations that significantly differed between sexes, many of which were related to smoking behaviors, familial smoking, and cotinine levels. Tobacco smoke is a significant source of exposure to heavy metals, such as cadmium and lead 34 , 35 , 36 , 37 , and volatile compounds like benzene, toluene, ethylbenzene, and xylene 38 . Exposure to these substances can be interpreted as exposure to both active and passive tobacco smoke. Our findings indicate that the effects of heavy metals and volatile compounds on phenotypes, such as serum albumin, closely mirror the impacts of smoking behaviors, as reflected in cotinine levels and self-reported smoking information. For instance, cadmium exposure in males had a similar impact on albumin levels as direct measures of smoking, such as cotinine.

Previous studies have documented sex differences in the prevalence and health impacts of smoking 39 , 40 . Our research further supports these differences, showing that smoking-related exposures have distinct associations with various phenotypes in males and females. For example, smoking is associated with elevated homocysteine (Hcy) levels 41 , and smoking and elevated Hcy levels have been associated with increased risks of cardiovascular disease and COPD 42 , 43 , 44 , 45 . Although males generally have higher Hcy levels than females, smoking exacerbates Hcy levels more in females, potentially due to hormonal mechanisms, including estrogen’s role in methionine metabolism 46 . Therefore, females might be at greater risk of the harmful effects of elevated Hcy levels than males 41 , 47 , including cardiovascular disease 3 , 48 and COPD 4 . Our study’s findings support sex differences in the effects of tobacco smoke exposure on Hcy. For example, the number of cigarettes currently smoked per day and the frequency of cigarette smoking during the past 30 days were positively associated with plasma Hcy levels only in females. Similarly, the average number of cigarettes smoked per day in the last 30 days had a greater effect on Hcy levels in females.

Smoking exposure has been linked to elevated levels of red blood cell populations, including hematocrit, hemoglobin, and red cell counts 49 , 50 . This increase is thought to result from carbon monoxide inhalation, which induces hypoxia and triggers a compensatory rise in hemoglobin, hematocrit, and red cell counts to maintain oxygen transport 51 , 52 , 53 . Our study found that smoking behavior, familial smoking, cotinine levels, and blood concentrations of cadmium, lead, ethylbenzene, and toluene were positively associated with hematocrit, hemoglobin, and red cell counts in females, consistent with prior research. However, to our knowledge, this study is the first to identify potential sex differences in the impact of tobacco smoke exposure on red blood cell populations.

On the other hand, tobacco smoke exposure significantly impacts inflammation and oxidative stress, primarily due to the presence of reactive oxygen species (ROS) that induce oxidative stress, leading to cellular apoptosis and senescence 54 . Typically, plasma antioxidants like albumin and bilirubin increase in response to oxidative stress as a protective mechanism 55 . However, studies have shown that smoking is associated with reduced levels of these antioxidants, even in a dose-dependent manner 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 . The excessive free radical production and extreme oxidative stress from smoking likely lead to the breakdown and depletion of these antioxidants, resulting in their lower levels 64 , 65 . Furthermore, smokers have also been found to exhibit elevated levels of inflammatory markers compared to non-smokers, including C-reactive protein (CRP), white blood cell count, and interleukin-6 62 , 66 , 67 , 68 . Although the exact mechanisms are unclear, albumin levels tend to decrease in response to acute inflammation 69 . The combined oxidative stress and inflammatory responses to tobacco smoke exposure elevate the risk of chronic diseases such as cancer, COPD, and cardiovascular disease 54 , 70 .

In our study, smoking behavior, familial smoking, cotinine levels, and cadmium exposure were negatively associated with serum albumin levels in males but not in females. Additionally, smoking behavior, including the number of cigarettes smoked daily and the average number of cigarettes smoked daily over the past month, was negatively associated with bilirubin levels, with stronger effects observed in males. Moreover, smoking behavior and blood cadmium levels were positively associated with CRP levels and white blood cell counts, again with greater effect sizes in males. These findings align with previous research highlighting the role of tobacco smoke in promoting oxidative stress and inflammation. However, only a few studies have reported sex differences in the associations between tobacco smoke exposure and inflammatory markers or antioxidants 56 , 71 . Our findings suggest that males may experience a heightened inflammatory and oxidative stress response to tobacco smoke exposure compared to females. Notably, most observed differences were quantitative, indicating that these effects also occur in females but are less pronounced.

The findings from this study underscore the significant sex differences in the biological mechanisms underlying tobacco smoke exposure. These differences manifest in various processes, including inflammation, oxidative stress, hypoxia, and Hcy metabolism. Future research and prevention strategies must consider these sex-specific variations. For instance, methodological designs should go beyond merely controlling for sex and actively account for these differences. In this study, tobacco smoke exposure was assessed using multiple measures, including direct blood cotinine levels and self-reported smoking behavior. The consistent observation of sex differences across these varied metrics reinforces the robustness of our results. Going forward, researchers can leverage the extensive NHANES dataset to develop more detailed exposure metrics that distinguish between primary and secondary exposure and capture the duration and intensity of exposure.

We found that serum albumin levels seem more susceptible to environmental exposures in males than in females. Of the 22 pure or quantitative sex-specific associations involving serum albumin levels, 20 were exclusive to males or had a greater effect size in males. By contrast, associations involving serum Hcy levels tended to be specific to females. In all five pure or quantitative sex-specific associations involving serum Hcy, the effect was either exclusive to females or stronger in females than males. These results suggest that sex-specific mechanisms might underlie the metabolism of Hcy and serum albumin, implicating sex differences in methionine catabolism and inflammatory responses.

Our study identified three distinct types of sex differences in the associations between environmental exposures and phenotypes: pure, quantitative, and qualitative. Each type of difference has unique implications for understanding sex-specific environmental effects and developing targeted interventions. Pure sex differences occur when a significant association is observed in one sex but not in the other. This type of difference suggests that the biological mechanisms underlying the response to this exposure are either absent or not as pronounced in one sex. Pure sex differences often point to sex-specific biological pathways that may be influenced by factors such as sex hormones or genetic differences. Understanding these mechanisms can help identify potential targets for therapeutic interventions that are tailored to one sex. On the other hand, quantitative sex differences occur when an association is present in both sexes but with varying magnitudes of effect, suggesting that while both sexes are affected, the impact is greater in one sex. Quantitative differences highlight the need for sex-specific thresholds or guidelines in clinical practice. For example, our findings suggest that smoking exposure has a greater effect on Hcy levels in females, which can lead to more tailored interventions. Finally, qualitative sex differences occur when the direction of the association is opposite in males and females. Such opposite effects suggest fundamentally different biological responses to the same exposure in each sex, which have significant implications for tailored interventions and therapeutic guidance.

Of the 119 significant sex-specific associations identified in our PheEWAS, 94 were pure or quantitative, and only 25 were classified as qualitative. This favor toward quantitative and pure sex differences suggests that males and females tend to differ in the degree of associations but not in the direction of effects. Furthermore, quantitative and pure sex differences suggest associations with the same underlying mechanisms in males and females, whereas qualitative differences suggest associations with different mechanisms in males and females. Some differences, which are, in fact, quantitative, might have been misclassified as pure because of a lack of power to detect a significant association in one of the sexes. On the other hand, qualitative differences suggest completely different mechanisms or responses in each sex. The different underlying mechanisms of qualitative sex differences and pure or quantitative sex differences might also explain why qualitative differences were rarer and more heterogeneous than pure or quantitative differences. Pure and quantitative sex differences showed greater similarities than qualitative sex differences in the exposures and phenotypes involved, for example, smoking-related exposures. The observed bias can have implications for future research, particularly in suggesting experimental designs and analyses that privilege detecting differences in effect sizes between sexes. Nevertheless, the bias towards pure and quantitative sex differences might be due to the higher power to detect pure and quantitative sex differences at the expense of qualitative differences.

We replicated 54 exposure-phenotype associations using a younger cohort that retained roughly half of the participants. These replicated findings corroborated the results obtained in the entire cohort regarding the differential effects of tobacco smoke exposure between sexes. The non-replicated exposure-phenotype might be due to the lower sample sizes and, therefore, the reduced power to detect those differences. The unique exposure-phenotype associations that were present only in the young cohort might be due to age-specific differences, including differences in exposure rates in younger versus older participants. Nevertheless, our study did not rigorously test differences between the full and young cohorts, which is beyond the scope of our study. This requires a two-way interaction between sex and age, necessitating substantial sample sizes to estimate and detect significant differences. Therefore, these differences remain speculative, and comparisons between the full and young cohorts are only descriptive.

While this study provides valuable insights into sex-specific associations between environmental exposures and health outcomes, several limitations that could affect the interpretation of our findings must be acknowledged. One of the primary limitations of this study is the exclusion of participants with missing data on covariates, which was necessary to maintain the integrity and consistency of the dataset. While this approach helps ensure that all included participants have complete data for the variables under consideration, it may introduce selection bias, potentially affecting the study’s findings. In short, excluding participants with missing data can lead to a non-random sample that might not fully represent the broader population. This selection bias could manifest in several ways, including underestimating or overestimating associations, reduced generalizability, and losing statistical power. Future studies could employ several strategies to mitigate these potential biases, including multiple imputation techniques and sensitivity analyses.

PheEWAS involves testing thousands of associations simultaneously, which increases the risk of Type I errors (false positives). Although we applied the Bonferroni correction to account for multiple comparisons, a widely used method for controlling the risk of false positives, it is overly conservative, particularly in studies with many comparisons. This conservativeness can increase the risk of Type II errors (false negatives), where true associations may be overlooked because the adjusted p-value threshold is too stringent 72 . In the context of our study, this could result in missing potentially sex-specific associations between environmental exposures and phenotypes. Given the limitations of the Bonferroni correction, alternative methods such as False Discovery Rate (FDR) can be used in future studies that balance the risk of Type I and Type II errors more effectively but still may lead to some false discoveries 73 .

Another caveat to our study is that sex differences in the range of variation of the exposures might be observed as sex differences in the association between exposures and phenotypes. For example, if males have a minimal range of variation in a given exposure, there might not be enough variation to detect an association with a given phenotype. In contrast, if females have a greater range of variation in the exposure, it can reveal a positive association between the exposure and the phenotype. In such a case, a phenotype-exposure association would differ between males and females only because of the different degrees of exposure and not necessarily because of different underlying mechanisms. Future research might benefit from detecting significant sex differences in the distributions of the exposures and either removing those exposures or flagging them for potential manual inspection.

Although we identified several exposure-phenotype associations, because of the cross-sectional nature of the data, we can only determine correlations between exposures and phenotypes and not causality 74 . Furthermore, although we adjusted for several known confounders, residual confounding may still exist due to unmeasured or unknown factors. Finally, reverse causality remains an issue, as in EWAS more generally 74 . For example, several sex-different associations might be due to differential behaviors that men and women deploy in the face of similar events. In other words, individuals with pre-existing health conditions may alter their behaviors or environments in ways that influence their exposure levels. Such behavioral differences are not trivial in analyses of sex differences because studies have shown gender differences in health-related behaviors such as healthcare seeking and medication intake and adherence 75 , 76 , 77 . Therefore, our results cannot easily be ascribed simply to sex differences if we understand them solely based on biology.

Finally, the generalizability of our findings may be limited by the demographic characteristics of the NHANES sample, which, while representative of the U.S. population, may not capture the full diversity of global populations. Factors such as ethnicity and environmental exposures vary widely across different populations, and the associations observed in this study may not apply universally 22 .

Our study unveils novel insights into the sex-specific effects of environmental exposures on health outcomes, highlighting this research’s unique and significant contribution to the field. First, it underscores the need for a deeper understanding of biological mechanisms driving these differences. Identifying sex differences is the first step in discovering potential biological mechanisms that might include hormonal, genetic, and epigenetic influences. With a better understanding of these mechanisms, sex differences become a crude reflection of a more nuanced underlying biology. Second, our study underscores the pressing need for a precision medicine approach that not only relies on genetic background but also on low-throughput demographic information, such as sex, to assess differences in treatments, diagnoses, and prognoses, thereby providing a practical framework for healthcare professionals and policymakers. It also foregrounds the relevance of targeted public health policies. For example, public health policies might address the needs of diverse subgroups differently to mitigate risks produced by environmental exposures, such as tobacco smoke. Finally, future studies have the potential to address two crucial missing pieces in our study: longitudinal variation and multidimensional exposures and phenotypes, thereby paving the way for further significant advancements in this field. We have taken a more straightforward approach in our study by taking a snapshot of the effects of environmental exposures on endophenotypes, but differences in intensities, duration of exposures, and lifespan window can modulate these effects. Furthermore, multiple exposures can affect multiple phenotypes in non-linear and more complex ways.

Data availability

The datasets analysed during the current study are available in the DataDryad repository, under the following DOI: https://doi.org/10.1038/sdata.2016.96 . All the code used during the current study are available in the Zenodo repository, under the following DOI: https://zenodo.org/doi/10.5281/zenodo.6483502 .

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Moving Forward with Reporting Back Individual Environmental Health Research Results

Affiliations.

• 1 Department of Environmental Medicine, University of Rochester, Rochester, New York, USA.
• 2 Silent Spring Institute, Newton, Massachusetts, USA.
• PMID: 38095662
• PMCID: PMC10720702
• DOI: 10.1289/EHP12463

Background: The practice of reporting back individual results to participants in environmental health research has evolved significantly over the past 20 years. Research findings support the potential of report-back to enhance the ethics, quality, and impact of environmental health research. Nonetheless, implementation of environmental health report-back practices is not yet routine.

Objectives: We propose a framework for institutionalizing appropriate report-back to participants of their individual results across the environmental health research enterprise. We provide a brief overview of the rationales for report-back, social science research on report-back experiences over the past two decades, and recent efforts to synthesize guidance in this field. We also describe barriers to be addressed in moving toward widespread implementation of report-back.

Discussion: Report-back of individual results is increasingly recognized as an ethical responsibility and essential component of impactful environmental health research. Experience shows that when personal results are returned with appropriate contextual information, report-back can increase environmental health literacy, promote individual actions, and enhance engagement in policy change. Therefore, report-back can promote environmental justice and reduce disparities in access to science. Despite this evidence base, report-back is not widely implemented. We recommend the collaborative development of guidelines, training, and resources to build capacity for appropriate report-back to study participants across the environmental health research enterprise, and we identify research priorities to advance the field. Development of tools and shared infrastructure for report-back holds promise for reducing barriers while ensuring high-quality personalized reports. Disseminating successful case studies could also advance excellence. We recommend including diverse scientific disciplines, community partners, representatives of study populations, clinicians, institutional review boards (IRBs), legal experts, public health professionals, and government officials in further developing this critical aspect of environmental health research. https://doi.org/10.1289/EHP12463.

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Children's environmental health

A safe, healthy and protective environment is key to ensuring all children can grow and develop to their full potential. In 2016, reducing environmental risks could have prevented almost 1.6 million deaths in children under 5 years. 

Children are particularly vulnerable to environmental risks, including air pollution, hazardous chemicals, climate change, and inadequate water, sanitation and hygiene.

In 2017, WHO published the second edition of Inheriting a sustainable world: The atlas on children's health and the environment,  which outlines the impact of the environment on children’s health and recommends solutions for preventing diseases and deaths in the future.

Approximately 1 in 4 child deaths could be prevented by reducing environmental risks

In 2016, environmental hazardous were attributable to more than 28% (or almost 1.6 million) of global deaths in children under 5 years of age. 

Global climate change is threatening the health of children in every region of the world and is a fundamental threat to humanity

Global climate change is threatening the health of children in every region of the world. Children are particularly vulnerable to the effects of climate change-related vulnerabilities, and children in the poorest countries are at the highest risk. UNICEF’s Children’s Climate Risk Index found in 2021 that almost all children in the world are at risk of at least one climate-related risk and approximately 1 billion children live in extremely high-risk countries. 

Air pollution is one of the greatest environmental risks to child health

WHO estimates that in 2019, 99% of the world’s population lived in locations where air pollution exceeded the WHO guidelines, placing their health and development at risk. Additionally, in 2020, around 30% of the world’s population relied on pollution fuels and technologies for cooking. Globally in 2019, the joint effects of ambient and household air pollution were attributable to around 317, 000 deaths in children under 5 years of age. Most of these deaths occurred in low- and middle-income countries. Air pollution is strongly linked to increased risk of acute lower respiratory infections in children and prenatal exposure is associated with increased risk of stillbirth, miscarriage and neurological conditions.

Access to safe water, sanitation and hygiene could prevent more than 443 000 deaths in children under 5 years of age

Access to safe water and sanitation and hygiene facilities is a universal need and a human right. The number of children dying from diarrhoeal diseases has fallen from approximately 1.2 million in 2000 to an estimated 443 000 in 2021 due to various public health accomplishments. However, they remain among the leading causes of global mortality in children under the age of 5. A significant proportion of diarrhoeal disease can be prevented through safe drinking-water and adequate sanitation and hygiene.

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Malaria is one of the leading causes of child mortality. In 2022, there were 608 000 deaths from malaria globally. Children under 5 years of age accounted for 76% of all deaths. WHO’s African Region carries a disproportionately high share of the global malaria burden and accounted for 94% of malaria cases and 95% malaria deaths in 2022.

E-waste is the fastest growing solid waste stream in the world

Each year millions of electrical and electronic devices are discarded as products break, or become obsolete, and are discarded by consumers. The discarded devices are considered e-waste and can become a threat to the environment and to human health if they are not treated, disposed of and recycled appropriately. E-waste contains many toxic substances that pose risks to human health if it is not recycled properly, including lead. Children are at high risk to hazardous substances that are released or produced through inappropriate e-waste recycling activities. See E-waste and child health and Children and digital dumpsites for more. 

Chemicals are ubiquitous in children’s lives

Children are exposed to chemicals everyday. While many chemicals are useful; their production, use and disposal can pose risks to children’s health. Toxic chemicals of concern to children include lead, mercury, some pesticides, persistent organic pollutants, arsenic and mycotoxins. Of particular concern to children’s health are chemicals that are known or suspected neurotoxicants, such as lead. These chemicals can cause profound and permanent damage to children’s development nervous systems. 

Unintentional injuries accounted for more than 266 000 deaths in children under 5 years of age in 2021

The top 5 unintentional injuries that caused child mortality in 2021 were road injuries, drowning, exposure to fire, heat and other hot substances, poisoning and falls. Children who survive injury may have life-long disability. 

Unintentional poisonings are an important source of childhood mortality

Children are particularly vulnerable to poisons due to their smaller size and less developed physiology, and because they like to explore and mouth items. Common poisons include pesticides and other household chemicals, such as petrol, kerosene and solvents, as well as toxins from various plants and animals. Almost all deaths from unintentional poisoning in 2021 occurred in low- and middle-income countries. The number of poisoning cases is an under-reported and under-recognized major public health concern.

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Moving Forward with Reporting Back Individual Environmental Health Research Results

Katrina smith korfmacher.

1 Department of Environmental Medicine, University of Rochester, Rochester, New York, USA

Julia Green Brody

2 Silent Spring Institute, Newton, Massachusetts, USA

Author J.G.B. was involved in/contributed to the NASEM report and DERBI software discussed in the article. The other author has no conflicts to disclose.

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Background:

The practice of reporting back individual results to participants in environmental health research has evolved significantly over the past 20 years. Research findings support the potential of report-back to enhance the ethics, quality, and impact of environmental health research. Nonetheless, implementation of environmental health report-back practices is not yet routine.

Objectives:

We propose a framework for institutionalizing appropriate report-back to participants of their individual results across the environmental health research enterprise. We provide a brief overview of the rationales for report-back, social science research on report-back experiences over the past two decades, and recent efforts to synthesize guidance in this field. We also describe barriers to be addressed in moving toward widespread implementation of report-back.

Discussion:

Report-back of individual results is increasingly recognized as an ethical responsibility and essential component of impactful environmental health research. Experience shows that when personal results are returned with appropriate contextual information, report-back can increase environmental health literacy, promote individual actions, and enhance engagement in policy change. Therefore, report-back can promote environmental justice and reduce disparities in access to science. Despite this evidence base, report-back is not widely implemented. We recommend the collaborative development of guidelines, training, and resources to build capacity for appropriate report-back to study participants across the environmental health research enterprise, and we identify research priorities to advance the field. Development of tools and shared infrastructure for report-back holds promise for reducing barriers while ensuring high-quality personalized reports. Disseminating successful case studies could also advance excellence. We recommend including diverse scientific disciplines, community partners, representatives of study populations, clinicians, institutional review boards (IRBs), legal experts, public health professionals, and government officials in further developing this critical aspect of environmental health research. https://doi.org/10.1289/EHP12463

Introduction

Community-engaged environmental health research teams have been leaders in communicating individual as well as study-wide results to research participants. Their efforts have aimed to fully engage research participants, 1 , 2 build environmental health literacy, 3 and inform individual and collective action. 4 They have developed ethical frameworks, 5 , 6 practical approaches, 7 and user-friendly tools 8 , 9 for reporting results across a wide domain of environmental health research that involves exposure measurements in biological or environmental samples. The practice of returning individual-level results to research participants, which we refer to here simply as “report-back,” has raised a variety of ethical, 5 , 6 , 10 – 12 practical, 8 , 9 , 11 , 13 , 14 and legal 15 questions. 5 , 13 To address these questions, research partnerships have engaged in an iterative process of implementing report-back, evaluating processes and outcomes, revising practices, and fielding new research to improve methods and build a generalizable evidence base for report-back methods. These approaches have yielded significant benefits for individuals, communities, and policy solutions. 11 , 16 – 18 Nonetheless, the practice of report-back has not been fully developed, disseminated, and implemented across the environmental health research enterprise. 14 According to Lebow-Skelley et al., 19 “despite the many recommendations to return research results to study participants, there continue to be many barriers to implementing this practice, including financial support, lack of expertise, lack of established approaches, and institutional approvals.” We believe that the growing practice of report-back is particularly timely given the increasing emphasis on community engagement in research; attention to environmental justice, diversity, and inclusion; research on ways to address complex problems like climate change; and efforts to increase environmental health literacy. Many research teams have observed that report-back provides an important opportunity to increase environmental health literacy, understanding of the scientific process, and trust in science. 11 , 20 , 21 Indeed, report-back has been found to increase participants’ capacity to engage in public policy, 2 , 13 , 22 which is necessary to address many environmental health problems—from hazardous waste cleanup to toxic substances regulation to climate change.

This commentary provides a brief overview of the multiple rationales for report-back of research results, emphasizing the particular relevance to environmental health research of this growing practice. We propose initial actions to support expansion of report-back of environmental health research results that include developing and disseminating guidelines, training, and resources.

Previous Research and Initiatives

Our recommendations build on the substantial body of research and initiatives on report-back that have accumulated over the past two decades. Previous research has found that nearly all study participants wanted to receive their results and perceived value beyond clinical relevance. 11 , 23 , 24 Studies consistently have shown that participants learn from their reports. They gained knowledge about exposure sources, readily brainstormed about strategies to reduce exposures, and expressed intentions to change behaviors. 17 , 25 In studies of consumer product chemicals and household contaminants, report-back generated conceptual shifts about the nature of pollution, raising awareness that potentially harmful chemicals enter the body from consumer products and linger in household air and dust. 20 In communities with a history of industrial pollution sources, participants integrated information about their personal exposure with larger understandings of the health and economic history of their community. 26 , 27 Seeing their own results motivated participants to change behaviors to reduce exposures, and some individuals became involved with local organizations working on policy solutions. 22 In addition, the desire to receive results was identified by participants as a motivator for study recruitment. 28

To develop reports that are practical for the research team and meaningful for participants, studies have sought input from community partners and study participants and conducted user-testing for reports. 7 , 29 , 30 Evaluations of report-back practices have assessed the usefulness of data, 31 learning outcomes, 3 , 32 the readability of graphs 29 and text, 25 and the use of data physicalizations. 33 Technical tools have been developed to facilitate report-back. For example, the Silent Spring Institute developed the Digital Exposure Report-Back Interface (DERBI), an online framework to produce personalized reports for computer, smartphone, or print. 8 Another effort, Macro for Compilation of Reports (MCR) uses Excel to automate aspects of report preparation. 9

While researchers and institutional review boards (IRBs) have often anticipated that participants would be overly concerned by their results, 14 studies that thoughtfully returned results and interpretive information reported that participants responded positively and without undue worry. 13 , 34 , 35 Participants’ increase in concerns have been appropriately associated with results showing the highest exposures in comparison with others. 34 In 2018, a consensus report of the National Academies of Sciences Engineering and Medicine (NASEM) concluded that concerns about the risks of communicating results had been overstated and that the benefits to participants and the research enterprise have been underestimated. 11 The NASEM report highlighted that participants have perceived benefits from report-back even when the links between exposure and health were poorly understood and remediation strategies were not known. For example, when a 2006 pilot study unexpectedly found higher-than-expected levels of serum perfluorooctanoate (PFOA) in a group of girls in the Growing Up Female Study, parents expressed gratitude for honesty in report-back even though the investigators had not identified the source and could not clarify the health implications. 21

As this brief summary shows, there is a robust and growing body of research on and experience with the practice of report-back. 36 To make further progress, several recent efforts have sought to identify needs and next steps to advance implementation of appropriate report-back of environmental health research results. These include the 2018 consensus report of NASEM, the 2018 Partnerships in Environmental Public Health annual meeting focused on report-back, and the 2022 Workshop on the Ethical, Legal, and Social Implications of Gene-Environment Interaction Research convened by the National Institute of Environmental Health Sciences (NIEHS) and National Human Genome Research Institute (NHGRI). 11 , 12 , 18 All of these efforts emphasized the need for institutional system changes to support timely implementation and further development of these practices.

Multiple entities are actively exploring how to promote appropriate report-back. In April 2022, the Department of Health and Human Services released a Request for Information with a specific request for input on a Priority Action to “Report research data to communities using culturally appropriate and accessible methods” (Strategy IV: Research and Data Collection, Analysis, Utilization). 37 Additionally, the 2023 National Institutes of Health (NIH) Data Management and Sharing Policy has elevated conversations about report-back in the context of increasing access to individual-level data. In addition to concerns about the effectiveness of de-identification measures, limitations on future use, and communication of sharing in consents for individual data, this policy highlights ethical questions about researchers sharing data that has not been returned individually to study participants. 38 Thus, this new policy may accelerate the development of models for community engagement in data sharing. Although, to our knowledge, no NIH grant solicitations have required development of a report-back plan, NIEHS has funded some studies that include report-back, including several studies focused on developing, assessing, and evaluating various aspects of report-back. For example, report-back is included in some cohorts within the Superfund Research Program, 39 the Environmental Influences on Child Health Outcomes (ECHO) Program, 40 Breast Cancer and the Environmental Research Program (BCERP), 41 and the NIEHS intramural Gulf Long-Term Follow-up (GuLF) Study. 42 Finally, in the U.S., indigenous communities have been leaders in creating processes and structures for maintaining data sovereignty, control over report-back of data, and community review of environmental health research findings prior to publication. 43 – 46

In addition to drawing on existing research, past experience, synthetic efforts, and policy proposals, this commentary also reflects the authors’ experiences as environmental health researchers and community engagement professionals. This experience includes our roles as former members of the National Advisory Environmental Health Sciences Council, where multiple discussions in Open Session have addressed the challenges, needs, and opportunities for report-back in the context of the NIEHS strategic plan, particularly regarding community engagement, environmental justice, and research translation. A 2022 Environmental Factor “Directors Corner” article set the stage for our reflections on these discussions. 47

Taken together, past efforts suggest that report-back is an essential component of environmental health research involving human participants. We propose that the time has come to systematically integrate appropriate report-back into the environmental health research enterprise. Many different perspectives need to be incorporated in this effort, including those of researchers, community members, research funders, public health professionals, environmental agencies, IRBs, legal experts, scientific review professionals, and health care providers. We believe that past research and practice provide compelling rationales and a solid foundation for moving forward; however, we recognize that much work remains to develop guidelines for varied research contexts, training for multiple stakeholders, and resources to support appropriate report-back. This commentary sets forth a framework for a collaborative approach to advancing implementation of report-back of individual environmental health research results.

Characteristics of Environmental Health Research Relevant for Report-Back of Individual Results

Many fields are revisiting practices, guidelines, and ethical standards for report-back of research results. However, several characteristics of environmental health research raise particular ethical, legal, and practical considerations for sharing individual results. While these characteristics are not unique to environmental health, we observe that they have elevated interest in report-back in this field over the past two decades. For example:

• Many environmental health findings do not meet traditional health-based criteria for reportability. For example, there may not be a clinical standard for an “unsafe” level of the chemical being studied, and research results may not have been generated by a laboratory certified under the Clinical Laboratory Improvements Amendments (CLIA) that provide quality assurance for diagnostic health assessments. 11
• Interpreting environmental health research results often involves uncertainty about what contributed to the exposure and what individual action, if any, could reduce exposure. 7 , 18
• Particularly in the US, where the system of regulating chemicals is not precautionary, 48 , 49 emerging research may detect potential health effects from chemicals that are unregulated or at levels below current standards. Withholding these results removes individuals’ ability to make their own decisions about risk based on emerging, yet uncertain information.
• Many environmental exposures result from the actions of others, and reduction of such exposures depends on collective action to promote prevention, rather than individual treatments, behaviors, or decisions. Situations in which solutions require systems change (rather than treatment of or action by individual patients) are common in environmental health. 1 Building collective understanding among similarly situated participants can support collective action.
• Techniques for measuring large numbers of environmental chemicals developed with the expansion of the National Exposure Report and other sampling programs in the early 2000s, and methods continue to expand rapidly, yielding large datasets of novel measurements in the context of exposomics and metabolomics investigations. 6
• Environmental health research may detect chemical exposures in individual participants that are relevant for other people who are similarly situated (family members, neighbors, co-workers, or community members). 6 , 18
• Environmental health research results may have legal, economic, or social implications for participants or other community members. Examples include effects on property values, real estate disclosures, liability and health insurance, and employability. 11 , 15
• Environmental health research is often conducted at the behest of and in partnership with community groups. 7 , 18 , 50 , 51 Community members may facilitate or participate in the research primarily because they want to get information about issues of personal concern. Particularly in such cases, research participants and partners may see themselves as co-owners of data.

Other fields of health research have grappled with report-back challenges similar to those for chemical exposures. For example, some genetic research findings may have implications for family members. 6 Much can be learned from these fields’ pioneering efforts. However, environmental health researchers often conduct biomonitoring studies in the context of broader community and policy relevance than genetic research. Thus, while much can be learned from report-back in other fields, environmental health research poses new challenges and complexities that merit special attention.

Breadth of the environmental health research field: implications for report-back.

The field of environmental health research is very broad. Different methodologies, types of data collected, and community context affect considerations for appropriate report-back. For example, environmental health data may include:

• Personal biomonitoring (e.g., blood, urine, teeth, fingernails)
• Personal exposure (devices that measure environmental exposures experienced by an individual person, e.g., backpack air monitors, silicon bracelets, radiation monitors)
• Personal environment (samples from the soil, indoor air, paint, dust, water, consumer products, or other exposure experienced by a particular group of people, e.g., at home, workplace, school)
• Ambient monitoring (samples of outdoor air, surface water, plants, animals in a defined geographic area)

Depending on the nature of the research, results may be shared with individual participants, study participants as a group, an affected community (for example, those similarly situated on the basis of living near where the study was conducted, holding the same occupation, sharing a historical exposure, having a disease history, etc.), and the general public. We focus here on report-back to individuals. However, the term “report-back” is sometimes used for all of these situations. Individual-level report-back often needs to be coordinated within a multilevel context of carefully sequenced communication. For example, it is widely accepted that individuals should get their own results from the research team before they learn about study-wide results in community meetings or from the news media. 52 Community meetings may support individual participants as well as informing broader constituencies. Although we focus here on individual level report-back, it is likely that the guidelines, training, and resources that address individual report-back are also relevant to other report-back scenarios.

Rationale for Report-Back

One of the early motivations for expanding individual report-back to include chemicals with uncertain health effects came from cases in which community members initiated research to address their concerns about environmental exposures and joined studies with an expectation that they would receive their own results. 1 As the field has developed, multiple rationales for report-back have been articulated. These arguments may be categorized as follows: ethical appropriateness, enhancing research quality, and advancing translational outcomes.

The ethical basis for report-back derives from the classic principles of autonomy, justice, beneficence, and nonmalfeasance and from additional public health values. 11 More recent interpretations of autonomy assert that individuals have a right to decide for themselves whether they want to know what is found from the personal information, biological samples, behavioral data, or environmental monitoring they provide. 6 , 11 Basic ethical principles also guide development of report-back approaches that maximize the benefits of the information to participants and mitigate potential negative effects, for example by providing resources to address concerns and guide constructive responses. 5 These recent interpretations represent an evolution from traditional clinical research guidelines, often still applied by IRBs, that do not adequately address technological innovations for monitoring new chemicals at the individual level. 5 , 6 Additionally, due to the interdependence of ecological and social factors that affect environmental exposures, broader public health ethical guidelines with an emphasis on prevention, participation, empowerment, community, equity, and timely solutions should be considered when developing appropriate report-back plans for environmental health research involving individual-level exposure assessments. 53 – 55

While ethical concerns have been primary drivers of these practices, report-back also has been shown to enhance the quality of research in many ways. First, many researchers have documented, both anecdotally and through systematic inquiry, that providing individual research results increases participants’ interest in contributing to research and to subsequent engagement throughout the research process. 3 , 11 , 27 – 29 , 56 , 57 These observations have clear implications for improving recruitment and retention. Second, in our own research 17 , 58 and in anecdotes reported to us by other researchers in interviews, 14 conference presentations, and informal conversations, there are examples in which interacting with individual participants about their study results helps researchers to glean new insights or formulate innovative research questions.

Finally, social science research has begun to explore the impacts of report-back on action. Although the literature is not yet extensive, studies to date have shown that participants who view their individual research results are motivated to change behaviors, such as which personal care products they purchase and their practices related to consuming water and food. 4 , 17 , 20 Participants were more engaged by individual- than only group-level results. 34 Returning research results has contributed to collective action based on common disease status, geographic community, and occupational history. 16 , 27 , 30 Additionally, researchers have documented participants’ intent to engage in policy action, both individually and through advocacy groups. 22 , 30

The overarching goal of promoting health equity spans all three of these rationales for individual report-back of study results. The ethical mandates for report-back are particularly strong in communities that bear disproportionate environmental burdens. The strong evidence that report-back supports action at the individual, community, or policy-level adds to the urgency of providing resources for participatory processes in environmental justice communities. In addition, the transparency involved in implementing report-back may help to build trust in science in minoritized communities affected by past research abuses and other forms of racism. 11 Because of these multiple rationales, appropriate report-back is a foundational principle of community-engaged research, especially in studies involving individual-level data collection in environmental justice communities. 2 , 50 , 51

These rationales for report-back may interact in complex ways. For example, effective communication of individual results can enhance participants’ environmental health literacy, which may in turn support their engagement in future research and policy change. It is important to bear in mind these multiple goals of report-back. Different justifications for report-back may matter more to some individuals and communities than others. We encourage researchers to make their rationale for and expectations of report-back clear to participants from the outset.

Social science research on report-back has robustly affirmed these multiple benefits. 36 Nonetheless, report-back has not been widely integrated into the practice of IRBs, funders, or researchers. At the same time, many questions remain about how to do so appropriately under diverse research and community scenarios. Several key areas for future research are highlighted in the conclusion of this commentary.

Challenges of Report-Back

The multiple rationales for and positive outcomes from report-back beg the question: why is report-back not more widely practiced now? Current challenges facing researchers contemplating individual report-back include the following:

• Regulatory oversight by IRBs: Some IRBs remain rooted in earlier ethical guidelines that restricted report-back to actionable results (i.e., above clinical health guidelines). 59 IRBs also may be unfamiliar with the concepts of co-ownership of data that underlie community engaged research and support right-to-know ethics. 59 Thus, some researchers may be blocked (or assume they would be blocked) by their IRB from reporting individual environmental health research results, which may have a chilling effect on expansion of report-back. 14 , 59 , 60
• Skills needed: Report-back requires multidisciplinary skills beyond those of many research teams. 18 For example, participants in an environmental epidemiological study may want to know where their exposures come from and how to reduce them, requiring input from exposure scientists. When an epidemiological study is investigating a novel hypothesis, communications about health implications must draw on expertise in toxicology and laboratory evidence. In addition, expertise in environmental health literacy is vital to reporting results in ways that appropriately communicate individual results and contextual information. Skills in communications, data visualization, and graphic design may also be needed.
• Communicating uncertainty: Given the goals of research to address new questions, report-back typically occurs in a context of limited information. Uncertainties may include the sources and routes of exposure, health implications, and effectiveness of exposure reduction strategies, and additional uncertainties may arise from limitations in study design. In some circumstances, researchers working in consultation with participant representatives may conclude that the contextual science about the measurements from new technologies is inadequate to give meaning to results. In general, however, effectively communicating to participants both what is known and what is not known is a core component of report-back.
• Concerns about harm: Despite the 2018 NASEM consensus study conclusion that report-back has benefits with little downside risk, we have observed that researchers who are not familiar with report-back frequently assume participants will overreact in harmful ways. 14 In a study that interviewed researchers who had reported back their results, many researchers said that they anticipated that participants would become overly alarmed, but they did not in fact observe undue concern when they did return results. 14 Nonetheless, there may be limited circumstances in which report-back is not beneficial or needs to be handled with added considerations. For example, in certain situations, report-back could contribute to stigma or raise legal obligations that need to be anticipated in informed consent.
• Financial resources: Report-back requires financial resources that may include staff time, technical support (e.g., graphic design), and communications (e.g., printing, meeting costs, mailing). These costs may be difficult to anticipate fully, for example when unexpected findings suggest follow-up testing, education, or action. Unless researchers budget appropriately for report-back in research proposals, these costs may impede report-back efforts.
• Timing for returning results: The time required for laboratory analysis and preparing a clean dataset may mean that report-back takes place years after the samples were collected and after the funding period ends. In addition, multiple contacts with participants may be needed over time, for example when additional analysis or review yields new findings. Ideally, the project should sustain capacity to address questions and concerns by participants for a period of time after they receive their results. Thus, financial, technical, and human resources to support report-back may need to extend beyond the time period of the initial grant.
• Grant review criteria and priorities: Perhaps the most fundamental barrier is that report-back is not required, explicitly considered in reviews, or scored as part of research funding programs. Therefore, researchers who devote budgetary resources to report-back may believe they will be at a disadvantage when their projects are reviewed compared to those who maximize funding for research activities. Researchers who do build report-back into their research plans may face the double jeopardy of having a smaller budget for research and reviewers judging the adequacy of their report-back plans in the absence of clear, established, research-based criteria for doing so. In other words, both researchers and reviewers currently are left to independently envision what is appropriate report-back. This gap creates uncertainty, confusion, and unpredictability and slows implementation of this practice.

As NASEM reported in 2018, “… as a matter of reciprocity, respect, transparency, and trust, the return of results should be routinely considered …” 11 But, what does this “consideration” entail? Based on our observations of evolving practices, we recommend development of guidelines, training, and resources to support dissemination and implementation of practices. To move forward toward this goal, we propose twelve recommendations for developing these three types of report-back supports ( Table 1 ). We are agnostic on who takes these steps but note that federal funding agencies are in a unique position to coordinate the convening, dissemination, and implementation of these approaches, as they have in other areas of research practice including human subjects’ protection, data management and sharing, and evaluation. Many groups may play a role in developing these supports, and we emphasize that diverse stakeholders in the research process should be engaged throughout.

Twelve recommendations for moving forward with reporting back individual environmental health research results.

We believe that an important step toward supporting report-back in a broad range of environmental health research is to develop and clearly communicate guidelines for appropriate report-back of individual results. Several efforts to develop guidelines for appropriate report-back have been undertaken but not completed. The most comprehensive effort to date is the 2018 NASEM consensus report, which recommended that every research proposal involving human biospecimens should have a report-back plan. 11 Different kinds of research, community contexts, and participant characteristics require different kinds of report-back. However, common high-level principles could guide development of standards, models, and plans for diverse research scenarios. These six recommendations for report-back guidelines lay out several general principles as well as suggestions for refining them in the context of varied research contexts and iterative learning over time.

1. Set expectations for participant-centric design.

At the highest level, the NASEM report emphasizes a participant-centric approach to decisions about report-back, taking into consideration that participants often see value in their results that is not obvious to the researchers. 51 This recommendation embodies the principle that participants, community partners, and other stakeholders should be involved in development of report-back plans. Guidelines should clarify this expectation for the process of development of research plans.

2. Specify components of report-back plans.

At a practical level, guidelines should specify key elements of report-back plans, such as what data will be shared, with whom, when, and how, and what contextual information will be included to help participants interpret their results. Contextual information in reports should routinely include information about the study investigators, funders, and review and advisory processes, including IRB oversight. Regarding “when” report-back occurs, current research practices and laboratory capacity sometimes result in substantial lag time between sample collection and availability of clean datasets ready for report-back. Guidelines should address how to account for both expected and unanticipated delays in availability of results. The relevance and actionability of significantly delayed results may merit particular consideration in report-back plans. For example, researchers may plan to share partial information to facilitate immediate action, rather than waiting for full study results to be available.

Several existing efforts provide a foundation for further development of report-back templates. For example, Silent Spring Institute’s When Pollution is Personal report-back manual includes tips such as giving participants the choice of receiving results or not, getting formative input on report-back plans and materials from community members, using text and graphics appropriate to the audience’s level of environmental health literacy, and including aggregate results to convey important study findings. 7 Another overview of report-back written in the context of promoting environmental health literacy provides a set of key questions to guide what should be included in participant reports. 1 The DERBI software tool also provides a model for how to communicate study results that addresses considerations including how to highlight important results for an individual, graphic benchmarks for comparison to national data or health guidelines, “details on demand” information about health and exposure reduction, ways of updating findings over time, and participant privacy. 8

3. Clarify strategies to appropriately communicate uncertainties.

Appropriate communication about uncertainty will likely require particular attention as these guidelines are developed. Each study team will face decisions about how to develop useful contextual information that clearly states what they believe to be true while acknowledging remaining uncertainties. Researchers may need guidance on how to do so without understating study findings or broader scientific knowledge. Additionally, new empirical investigations can continue to inform effective ways to communicate various forms of uncertainty, elucidate how diverse participants interpret communications about uncertainty, and clarify the values and preferences of participant groups in different settings.

Communicating both what is known and what is not known allows participants to apply their own values and preferences for risk-related choices. One way for researchers to explain uncertain health risks is to share the evidence and questions that motivate their research. While explaining uncertainties, we caution against downplaying that evidence. In our experience, researchers sometimes are inclined to give overly reassuring messages in order to not cause concern. However, doing so deprives participants of the opportunity to make their own decisions about whether or not to seek additional information or take precautionary action, and it can cause confusion later if health risks become clearer. Thus, helping researchers appropriately communicate uncertain information should be a central goal of report-back guidelines.

4. Convene stakeholders to refine guidelines for specific types of research.

Report-back is operationalized differently in varied research contexts. We recommend including stakeholders with diverse experiences and perspectives in refining guidelines for different types of environmental health research. One approach might be to convene a writing workshop of researchers, community partners, IRB representatives, and others to develop consensus guidelines for different fields, disciplines, and types of research. These efforts may result in more detailed rubrics for applying report-back principles in different cases. For example, report-back experts have developed templates for designing reports and a conceptual guide to the types of exposure-reduction actions to include in reports based on the level of knowledge of health effects and the efficacy of exposure reduction methods. 1 , 5 Frameworks like that created by Van Horne et al. for exposure science could be developed for other types of environmental health research. 43 These convenings may also identify areas in which additional report-back research is needed. For example, the Environmental Influences on Child Health Outcomes (ECHO) Program has supported grant supplements to develop report-back practices for specific research scenarios, such as biomonitoring of pregnant people.

5. Include report-back plans in relevant funding opportunities.

A powerful tool to advance the practice of report-back would be to state in grant application guidelines that research projects involving human exposure measurements should include a report-back plan. 11 , 18 At the same time, we believe it is important to acknowledge that individual report-back may not be desirable for all such studies. Any report-back plan requirement should provide an opportunity for researchers to explain unique challenges that preclude or limit individual report-back of results in their study. Integrating report-back plan requirements into funding opportunities would help assure that report-back is included in research design, budgets, and human subject protocols from the outset, rather than after the study is already underway. 7 , 18 Providing clear expectations, high-level guidelines for process and content, and evaluation criteria within proposal requests may both help researchers develop successful report-back plans and facilitate reviewers’ evaluation of these plans.

6. Disseminate report-back guidelines to affected stakeholders.

Clarifying, communicating, and disseminating guidelines could promote consistent and appropriate report-back. It is essential to actively disseminate these guidelines to all stakeholders in the environmental health research process, including researchers, community and government partners, and IRBs, in order to build a common understanding of appropriate approaches. The training and resource recommendations listed below suggest additional ways to support dissemination.

Although past work strongly supports the high-level principles and recommendations described above, there is ample opportunity for learning, refining, and adapting these guidelines as experience grows. To facilitate this process, When Pollution is Personal recommends that as report-back practices develop, they should be formally evaluated by documenting the approach, soliciting feedback from participants, and tracking impacts over time. 7 Integrating social science research into the implementation of environmental health research report-back would maximize learning, advance the field of report-back scholarship, and speed refinement of guidelines. Thus, while initial guidelines may be high-level, additional specification can be expected as experience grows.

Alongside development of guidelines for report-back, it is important to consider how to comprehensively train the environmental health research community in these practices. This includes building the capacity of both individuals directly involved in designing, reviewing, and conducting research and “external” stakeholders who may interact with the report-back process, including community groups, public health officials, clinicians, and relevant agencies.

7. Train research teams, reviewers, and institutional review boards.

As guidelines are developed, training will be needed to help research teams implement these principles in practice. As noted above, community engaged biomonitoring researchers have developed report-back approaches that can be used as a starting point. Additional resources may be developed for diverse constituencies and research areas. For example, researchers who lack community-engaged experience may need training in how to develop and implement participant-centric report-back plans. Training may also help researchers identify needs for new research team members or partnerships with others who can fill these roles.

Grant proposal reviewers and IRB members also must develop their capacity to support consistent, sustainable, and high-quality application of report-back. These constituencies may need training on how to evaluate report-back plans. In our experience, we have found that different IRBs have different interpretations of how to apply ethical principles for human subject research to report-back of environmental health results, 16 and they may be unaware of consensus documents and empirical research particular to this field. Therefore, training IRBs will be crucial for the successful implementation of these plans by different research institutions.

One relevant model for developing the capacity of research teams that engage with diverse communities is the NIEHS’s comprehensive effort to support, inform, and improve evaluation of environmental health partnerships. NIEHS staff collected, analyzed, and synthesized evaluation approaches from a wide range of community partnerships. They summarized the resulting case studies, recommendations, and practical advice into the Partnerships for Environmental Public Health Evaluation Metrics Manual . 61 , 62 These materials were disseminated through webinars, workshops, and conference presentations. Elements of the manual have been integrated into numerous NIEHS Requests For Applications that include community engagement. From our perspective, there is a strong consensus in the Partnerships for Environmental Public Health community of practice that these tools significantly improved evaluation practices. We believe that this has contributed to more rigorous, equitable, and impactful engagement programs across the environmental health enterprise. A similar manual and training campaign on report-back in environmental health research could form the basis for training research teams and guide expansion and excellence in this field.

8. Train external stakeholders.

Because effective environmental report-back often seeks to connect study participants with opportunities to act on their results, it often affects stakeholders outside the study team. Researchers need to learn how to identify, brief, and support such external stakeholders to participate constructively. Importantly, community partners may provide study participants with effective avenues for collective or policy action on their personal results. In addition, developing the capacity of health professionals, local health departments, and relevant community organizations to understand environmental health research results may help these groups support participants after research results are shared. For instance, the experience of per- and polyfluoroalkyl substances (PFAS)-contaminated communities showed the importance of educating clinicians so they can respond appropriately if their patients who participated in a study bring results to them. 32 , 63 Local agency staff and elected officials may also be engaged. For example, water suppliers may need to be alerted and included in report-back plans when personal results reveal public drinking water contamination. Training for community partners may increase their engagement in report-back processes and provide opportunities for two-way learning about ethics, methods, and approaches.

As discussed above in the section on extant challenges to report-back, resource limitations are commonly cited as a barrier to report-back. Accordingly, it seems likely that providing adequate financial, technical, material, and institutional resources would support wider implementation of the practice. We recommend identifying key resource gaps and developing resources to address them. In particular, we believe it is important to provide new funding mechanisms, create tools and shared infrastructure to facilitate cost-effective report-back, and develop technical resources specifically to support report-back of environmental health research results.

9. Provide appropriate financial resources.

Report-back requires dedicated financial resources. Study-specific funding could be part of the initial research grant or provided as a supplement. Importantly, these resource needs may extend beyond the typical funded grant period because of the timing of receiving, analyzing, and sharing results. Additionally, participants may have new questions and concerns over time. Some report-back efforts may benefit from flexible funding so they can provide follow-up testing after remedial actions are taken by the participant. New funding mechanisms should be considered to meet such unique needs, such as small post-grant awards or research supplements.

10. Create cost-effective tools and shared report-back infrastructure.

Report-back could be promoted through development of tools that offer high quality at low cost to individual research teams. Shared infrastructure can include user-tested text and design, science-based content libraries, and semi-automated ability to personalize results while maintaining the ability to tailor reports to specific community contexts. One example is DERBI, the Digital Exposure Report-Back Interface, developed by one of the authors (J.G.B.) and her team at Silent Spring Institute. 8 This tool has been used across a wide range of biomonitoring studies and household exposure studies with diverse populations and in multiple languages. 8 Researchers can use DERBI to develop reports that draw on a library of vetted contextual information and images that can be modified by the research team to suit their study, including input from community members or participants.

Continuing to develop tools that facilitate cost-effective report-back in multiple types of research is essential to reduce costs and other barriers for individual researchers, such as access to communications skills, technology to personalize results, and broad scientific context. Report-back infrastructure tools could be built into collaborative platforms for multi-site studies or hosted centrally so as to be available to all researchers, minimizing the costs to individual studies. For example, these frameworks could be available through the data centers for laboratory networks, such as the Human Health Exposure Analysis Resource (HHEAR) program, 64 or consortia, such as the Environmental Influences on Child Health Outcomes (ECHO) Program. 40

11. Develop technical resources to meet environmental health researchers’ needs.

Several specific technical resource gaps have been identified by environmental health report-back experts. For example, the 2018 NASEM report highlights the need to develop technical resources that provide appropriate standards for non-CLIA labs and report-back of these results. 11 In addition, as with genetic testing, legal resources that guide and support protections are needed so that environmental health research results cannot be used against participants, for example, by health insurance companies or employers. 10 , 15 Additional technical resource priorities are likely to surface as report-back expands into new arenas.

12. Focus on accessibility, equitability, and action.

Development of resources to support report-back should align with the goals of supporting environmental health action and reducing health inequities. For example, researchers at a university with environmental health-focused community engagement programs may leverage that experience to support report-back; others may lack such expertise. Therefore, low-cost tools, publicly accessible resources, training, and support for researchers and communities with limited institutional support should be prioritized. This recommendation also highlights the need to emphasize the user-friendliness of data sharing tools and infrastructure. Finally, variations in research participants’ environmental health literacy should be accommodated in the design of resources, programs, and tools to promote report-back.

Recommendations for Moving Forward Together

Report-back of environmental health research results is an important foundation of community engagement in research and public support for science. Environmental health research often informs individual, community, organizational, and policy-level action. In this commentary, we have described some of the past experience and research that has demonstrated the power of report-back of individual results to help translate research into action to improve environmental public health. 4 , 16 , 17 , 52 , 65 Additionally, research and practice have established strong rationales for implementation of report-back. Models of effective implementation have been demonstrated in multiple settings. 4 , 13 , 17 , 21 , 29 , 31 , 32 , 34 , 52 , 66 However, there are barriers to expanding this practice, including lack of financial support, demands on researchers’ time, the need for multidisciplinary expertise, uncertainty about communication approaches, and difficulty securing institutional approvals. To address these barriers, we believe that the research community needs guidelines, training, and resources to support appropriate report-back across the environmental health enterprise.

The emerging best practices of report-back are founded on extensive research on ethics, logistics, action impacts, and participant experiences. Nonetheless, additional research is needed to support institutionalizing report-back and continually improving report-back methods. Findings from social science studies on the report-back process can be integrated into guidelines over time in an iterative process. Thus, we recommend considering guidelines for report-back to be an evolving framework informed by evolving research and practice, rather than a static product. Some examples of key areas for future research include:

• How best to communicate findings, implications, and uncertainties to diverse audiences
• Appropriate protocols for communicating with participants with high outlier results
• Ethical and practical considerations for dissemination and implementation of environmental health report-back in clinic-based studies, medical monitoring, and clinical care
• Report-back issues unique to research on gene-environment interactions
• Potential approaches for report-back of results from pooled- or long-term cohort studies
• Identifying resources researchers need in order to apply digital report-back tools
• How report-back can help communities engage in systems changes that promote health equity

These and other research questions can be pursued iteratively with the development of guidelines, training, and resources to support appropriate report-back.

As discussed throughout this commentary, we believe that the process of advancing appropriate report-back practices must itself be participatory. Diverse perspectives, needs, and skills must be considered in creating guidelines, trainings, and resources to support report-back in environmental health research. Building the capacity of researchers, funders, IRBs, reviewers, and other partners will be essential to support successful implementation of these guidelines. A collaborative process for developing report-back resources will help ensure that the practice of report-back improves environmental public health, reduces health disparities, and translates environmental health research into action.

Acknowledgments

K.S.K. was supported in part by P30 ES 001247 from the National Institute of Environmental Health Sciences. J.G.B. was supported by R21ES032934 and P42ES017198.