Environmental health disparities: a framework integrating psychosocial and environmental concepts

Neighborhood-Level Lead Paint Hazard for Children under 6: A Tool for Proactive and Equitable Intervention

Lead is well known for its adverse health effects on children, particularly when exposure occurs at earlier ages. The primary source of lead hazards among young children is paint used in buildings built before 1978. Despite being 100% preventable, some children remain exposed and state and local policies often remain reactive. This study presents a methodology for planners and public health practitioners to proactively address lead risks among young children. Using geospatial analyses, this study examines neighborhood level measurement of lead paint hazard in homes and childcare facilities and the concentration of children aged 0-5. Results highlight areas of potential lead paint hazard hotspots within a county in the Midwestern state studied, which coincides with higher concentration of non-white children. This places lead paint hazard in the context of social determinants of health, where existing disparity in distribution of social and economic resources reinforces health inequity. In addition to being proactive, lead poisoning intervention efforts need to be multi-dimensional and coordinated among multiple parties involved. Identifying children in higher lead paint hazard areas, screening and treating them, and repairing their homes and childcare facilities will require close collaboration of healthcare professionals, local housing and planning authorities, and community members.

Differences in exposure to toxic and/or carcinogenic volatile organic compounds between Black and White cigarette smokers

OBJECTIVE

It is unclear why Black smokers in the United States have elevated risk of some tobacco-related diseases compared to White smokers. One possible causal mechanism is differential intake of tobacco toxicants, but results across studies are inconsistent. Thus, we examined racial differences in biomarkers of toxic volatile organic compounds (VOCs) present in tobacco smoke.

METHOD

We analyzed baseline data collected from 182 Black and 184 White adult smokers who participated in a randomized clinical trial in 2013-2014 at 10 sites across the United States. We examined differences in urinary levels of ten VOC metabolites, total nicotine equivalents (TNE), and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), controlling for covariates such as cigarettes per day (CPD), as well as differences in VOCs per TNE to assess the extent to which tobacco exposure, and not metabolic factors, accounted for racial differences.

RESULTS

Concentration of metabolites of acrolein, acrylonitrile, ethylene oxide, and methylating agents were significantly higher in Blacks compared to Whites when controlled for covariates. Other than the metabolite of methylating agents, VOCs per TNE did not differ between Blacks and Whites. Concentrations of TNE/CPD and VOCs/CPD were significantly higher in Blacks. Menthol did not contribute to racial differences in VOC levels.

CONCLUSIONS

For a given level of CPD, Black smokers likely take in higher levels of acrolein, acrylonitrile, and ethylene oxide than White smokers. Our findings are consistent with Blacks taking in more nicotine and toxicants per cigarette smoked, which may explain their elevated disease risk relative to other racial groups.

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

BACKGROUND

The combined effects of multiple environmental toxicants and social stressor exposures are widely recognized as important public health problems contributing to health inequities. However cumulative environmental health risks and impacts have received little attention from U.S. policy makers at state and federal levels to develop comprehensive strategies to reduce these exposures, mitigate cumulative risks, and prevent harm. An area for which the inherent limitations of current approaches to cumulative environmental health risks are well illustrated is children's neurodevelopment, which exhibits dynamic complexity of multiple interdependent and causally linked factors and intergenerational effects.

OBJECTIVES

We delineate how a complex systems approach, specifically system dynamics, can address shortcomings in environmental health risk assessment regarding exposures to multiple chemical and nonchemical stressors and reshape associated public policies.

DISCUSSION

Systems modeling assists in the goal of solving problems by improving the "mental models" we use to make decisions, including regulatory and policy decisions. In the context of disparities in children's cumulative exposure to neurodevelopmental stressors, we describe potential policy insights about the structure and behavior of the system and the types of system dynamics modeling that would be appropriate, from visual depiction (i.e., informal maps) to formal quantitative simulation models. A systems dynamics framework provides not only a language but also a set of methodological tools that can more easily operationalize existing multidisciplinary scientific evidence and conceptual frameworks on cumulative risks. Thus, we can arrive at more accurate diagnostic tools for children's' environmental health inequities that take into consideration the broader social and economic environment in which children live, grow, play, and learn. https://doi.org/10.1289/EHP7333.

An Intercategorical Ecology of Lead Exposure: Complex Environmental Health Vulnerabilities in the Flint Water Crisis

In 2014, city and state officials channeled toxic water into Flint, Michigan and its unevenly distributed and corroding lead service lines (LSLs). The resulting Flint water crisis is a tragic example of environmental racism against a majority Black city and enduring racial and spatial disparities in environmental lead exposures in the United States. Important questions remain about how race intersected with other established environmental health vulnerabilities of gender and single-parent family structure to create unequal toxic exposures within Flint. We address this question with (1) an “intercategorical ecology” framework that extends the “racial ecology” lens into the complex spatial and demographic dimensions of environmental health vulnerabilities and (2) a multivariate analysis using block-level data from the 2010 U.S. decennial census and a key dataset estimating the LSL connections for 56,038 land parcels in Flint. We found that blocks exposed to LSLs had, on average, higher concentrations of single-parent white, Black, and Latinx families. However, logistic regression results indicate that the likelihood of block exposure to LSLs was most consistently and positively associated with the percentage of single-father Black and single-mother Latina families, net of other racialized and gendered single-parent family structures, socioeconomic status, and the spatial concentration of LSL exposure.

Perceived Neighborhood Crime Safety Moderates the Association Between Racial Discrimination Stress and Chronic Health Conditions Among Hispanic/Latino Adults

Background: Little is known about the link between perceived neighborhood walkability and prevalence of chronic disease. Even less is known regarding this association among Hispanic/Latino adults, despite exhibiting high rates of chronic diseases. Stress due to racial discrimination is a harmful social determinant of health in Hispanics/Latinos. Having both low perceived neighborhood walkability and high racial discrimination stress may exacerbate the chronic disease status of Hispanics/Latinos. Among a U.S. national sample of Hispanic/Latino adults, this cross-sectional study aims to examine (1) the associations among overall perceived neighborhood walkability, racial discrimination stress, and having a chronic health condition; and (2) whether overall perceived neighborhood walkability moderates the hypothesized association between racial discrimination stress and having a chronic health condition. Methods: In January 2018, 798 Hispanic/Latino adults (M age = 39.7 years, SD = 15.1; 58.6% female; 70.0% U.S. born; 52.0% Mexican/Mexican American) responded to a survey via Qualtrics Panels. Surveys included the Neighborhood Environment Walkability Scale-Abbreviated, Hispanic Stress Inventory-2, and self-reported presence/absence of chronic health conditions (e.g., hypertension, heart disease). A logistic regression was conducted testing for the moderation of the main effect of racial discrimination stress on the presence of a chronic health condition by overall perceived neighborhood walkability. Results: After controlling for age, body mass index, and income, racial discrimination stress was inversely associated with overall perceived neighborhood walkability (b = -0.18, p < 0.001) and positively associated with having a chronic health condition (OR = 1.02; 95% CI [1.00, 1.03]). While overall perceived neighborhood walkability was not associated with having a chronic health condition, perceived crime safety was inversely associated with having a chronic health condition (OR = 0.94; 95% CI [0.89, 0.99]). Perceived crime safety moderated the positive association between discrimination stress and having a chronic health condition, such that the association was only significant among those who perceived their neighborhood to be less safe (β = -0.004, 95% CI [-0.01, -0.00]). Conclusions: Overall perceived neighborhood walkability was inversely associated with racial discrimination stress, but not associated with having a chronic health condition. Perceived neighborhood crime safety, but not infrastructure or aesthetics, matters when it comes to the link between racial discrimination stress and having a chronic health condition among Hispanics/Latinos.

Participatory Research for Environmental Justice: A Critical Interpretive Synthesis

BACKGROUND

Environmental health risks are disproportionately colocated with communities in poverty and communities of color. In some cases, participatory research projects have effectively addressed structural causes of health risk in environmental justice (EJ) communities. However, many such projects fail to catalyze change at a structural level.

OBJECTIVES

This review employs Critical Interpretive Synthesis (CIS) to theorize specific elements of participatory research for environmental health that effectively prompt structural change in EJ communities.

METHODS

Academic database search was used to identify peer-reviewed literature describing participatory research with EJ communities to address environmental health. Synthetic constructs were developed iteratively related to study characteristics, design elements, and outcomes; and data were extracted for included records. Statistical analyses were performed to assess correlations between study design elements and structural change outcomes. Through critical, comparative, and contextual analyses of the "structural change" case study group and "non- structural change" group, informed by relevant theoretical literature, a synthesizing argument was generated.

RESULTS

From 505 total records identified, eligibility screening produced 232 case study articles, representing 154 case studies, and 55 theoretical articles for synthesis. Twenty-six case studies resulted in a structural change outcome. The synthesizing argument states that participatory research with EJ communities may be more likely to result in structural change when a) community members hold formal leadership roles; b) project design includes decision-makers and policy goals; and c) long term partnerships are sustained through multiple funding mechanisms. The assumption of EJ community benefit through research participation is critically examined.

DISCUSSION

Recommended future directions include establishing structural change as a goal of participatory research, employing participatory assessment of community benefit, and increased hiring of faculty of color at research institutions. The power, privilege, and political influence that academic institutions are able to leverage in partnership with EJ communities may be as valuable as the research itself. https://doi.org/10.1289/EHP6274.

Principles of Researching Health Disparities in Longitudinal Cohort Studies Enrolling Children

Health disparities are defined on the basis of specific populations that, when compared to the general population, have a significant disparity on the rate of disease incidence, prevalence, morbidity, mortality, or survival. People that experience health disparities can be defined by multiple criteria. As the diversity of the United States broadens and increases, research on the origins and causes of health disparities becomes more important to support a healthy general population. Children are particularly sensitive to and vulnerable to health disparities due to the potentially life long consequences of events during periods of critical organ, intellectual and social development. The concept of health justice whereby each individual has the opportunity to realize their full health potential can only be realized with proper understanding and relevant data to frame practice, policy and actions. The National Children's Study (NCS) was a longitudinal birth cohort study designed to incorporate the principles of the Federal Collaboration on Health Disparities Research in consultation with subject matter experts, community representatives, and ongoing evaluation to ensure high quality and relevant data on factors that impact health outcomes. The NCS developed and tested a model of enrolling a diverse population, capturing and integrating data using a life course framework, constructing individual profiles, then aggregating individuals into groups based on profiles and outcomes. This approach is applicable to other longitudinal cohort studies.

Nationwide Study of Short-term Exposure to Fine Particulate Matter and Cardiovascular Hospitalizations Among Medicaid Enrollees

BACKGROUND

Fine particulate matter (PM2.5) has been consistently linked to cardiovascular disease (CVD). Although studies have reported modification by income, to our knowledge, no study to date has examined this relationship among adults in Medicaid, which provides health coverage to low-income and/or disabled Americans.

METHODS

We estimated the association between short-term PM2.5 exposure (average of PM2.5 on the day of hospitalization and the preceding day) and CVD admissions rates among adult Medicaid enrollees in the continental United States (2000-2012) using a time-stratified case-crossover design. We repeated this analysis at PM2.5 concentrations below the World Health Organization daily guideline of 25 μg/m. We compared the PM2.5-CVD association in the Medicaid ≥65 years old versus non-Medicaid-eligible Medicare enrollees (≥65 years old).

RESULTS

Using information on 3,666,657 CVD hospitalizations among Medicaid adults, we observed a 0.9% (95% CI = 0.6%, 1.1%) increase in CVD admission rates per 10 μg/m PM2.5 increase. The association was stronger at low PM2.5 levels (1.3%; 95% CI = 0.9%, 1.6%). Among Medicaid enrollees ≥65 years old, the association was 0.9% (95% CI = 0.6%, 1.3%) vs. 0.8% (95% CI = 0.6%, 0.9%) among non-Medicaid-eligible Medicare enrollees ≥65 years old.

CONCLUSION

We found robust evidence of an association between short-term PM2.5 and CVD hospitalizations among the vulnerable subpopulation of adult Medicaid enrollees. Importantly, this association persisted even at PM2.5 levels below the current national standards.

Relationship between Long-Term Residential Green Exposure and Individuals' Mental Health: Moderated by Income Differences and Residential Location in Urban China

Environmental health effects during urbanization have attracted much attention. However, knowledge is lacking on the relationship between long-term cumulative residential environment and health effects on individuals during rapid transformations in urban physical and social space. Taking Guangzhou, China, as a case example, this study analyzed the relationship between long-term exposure to green environments and residents’ mental health under urban spatial restructuring. Based on a household survey in 2016, 820 residents who have lived in Guangzhou for more than 15 years were used as the sample. High-resolution remote sensing images were used to assess the long-term green exposure of residents. The results indicate that long-term green exposure in residential areas had a negative correlation with residents’ mental health (p < 0.05), and the correlation was strongest for the cumulative green environment in the last five years. However, this significant effect was moderated by income and residential location. Green exposure had a positive relationship with mental health for low income groups, and a negative relationship for middle and high income groups. In addition, residents living farther away from the city center were likely to have fewer green environmental health benefits. Residential relocation in a rapidly urbanizing and transforming China has led to the continuous differentiation of residential green environments among different income groups, which has also caused different mental health effects from green exposure. It provides empirical evidence and theoretical support for policymakers to improve the urban environment and reduce environmental health disparities by considering social differences and residential location.

Guidance to Reduce the Cardiovascular Burden of Ambient Air Pollutants: A Policy Statement From the American Heart Association

In 2010, the American Heart Association published a statement concluding that the existing scientific evidence was consistent with a causal relationship between exposure to fine particulate matter and cardiovascular morbidity and mortality, and that fine particulate matter exposure is a modifiable cardiovascular risk factor. Since the publication of that statement, evidence linking air pollution exposure to cardiovascular health has continued to accumulate and the biological processes underlying these effects have become better understood. This increasingly persuasive evidence necessitates policies to reduce harmful exposures and the need to act even as the scientific evidence base continues to evolve. Policy options to mitigate the adverse health impacts of air pollutants must include the reduction of emissions through action on air quality, vehicle emissions, and renewable portfolio standards, taking into account racial, ethnic, and economic inequality in air pollutant exposure. Policy interventions to improve air quality can also be in alignment with policies that benefit community and transportation infrastructure, sustainable food systems, reduction in climate forcing agents, and reduction in wildfires. The health care sector has a leadership role in adopting policies to contribute to improved environmental air quality as well. There is also potentially significant private sector leadership and industry innovation occurring in the absence of and in addition to public policy action, demonstrating the important role of public-private partnerships. In addition to supporting education and research in this area, the American Heart Association has an important leadership role to encourage and support public policies, private sector innovation, and public-private partnerships to reduce the adverse impact of air pollution on current and future cardiovascular health in the United States.

What Do We Know About the Drivers of Health and Equity? A Narrative Review of Graphic Representations

Purpose: Frameworks can be influential tools for advancing health and equity, guiding population health researchers and practitioners. We reviewed frameworks with graphic representations that address the drivers of both health and equity. Our purpose was to summarize and discuss graphic representations of population health and equity and their implications for research and practice.

Methods: We identified publicly available frameworks that were scholarly or practice oriented and met defined inclusion and exclusion criteria. The identified frameworks were then described and coded based on their primary area of focus, key elements included, and drivers of health and equity specified.

Results: The variation in purpose, concepts, drivers, underlying theory or scholarly evidence, and accompanying measures was highlighted. Graphic representations developed over the last 20 years exhibited some consistency in the drivers of health; however, there has been little uniformity in depicting the drivers of equity, disparities or interplay among the determinants of health, or transparency in underlying theories of change.

Conclusion: We found that current tools do not offer consistency or conceptual clarity on what shapes health and equity. Some variation is expected as it is difficult for any framework to be all things to all people. However, keeping in mind the importance of audience and purpose, the field of population health research and practice should work toward greater clarity on the drivers of health and equity to better guide critical analysis, narrative development, and strategic actions needed to address structural and systemic issues perpetuating health inequities.

Who are more exposed to PM2.5 pollution: A mobile phone data approach

BACKGROUND

Few studies have examined exposure disparity to ambient air pollution outside North America and Europe. Moreover, very few studies have investigated exposure disparity in terms of individual-level data or at multi-temporal scales.

OBJECTIVES

This work aims to examine the associations between individual- and neighbourhood-level economic statuses and individual exposure to PM2.5 across multi-temporal scales.

METHODS

The study population included 742,220 mobile phone users on a weekday in Shenzhen, China. A geo-informed backward propagation neural network model was developed to estimate hourly PM2.5 concentrations by the use of remote sensing and geospatial big data, which were then combined with individual trajectories to estimate individual total exposure during weekdays at multi-temporal scales. Coupling the estimated PM2.5 exposure with housing price, we examined the associations between individual- and neighbourhood-level economic statuses and individual exposure using linear regression and two-level hierarchical linear models. Furthermore, we performed five sensitivity analyses to test the robustness of the two-level effects.

RESULTS

We found positive associations between individual- and neighbourhood-level economic statuses and individual PM2.5 exposure at a daytime, daily, weekly, monthly, seasonal or annual scale. Findings on the effects of the two-level economic statuses were generally robust in the five sensitivity analyses. In particular, despite the insignificant effects observed in three of newly selected time periods in the sensitivity analysis, individual- and neighbourhood-level economic statuses were still positively associated with individual total exposure during each of other newly selected periods (including three other seasons).

CONCLUSIONS

There are statistically positive associations of individual PM2.5 exposure with individual- and neighbourhood-level economic statuses. That is, people living in areas with higher residential property prices are more exposed to PM2.5 pollution. Findings emphasize the need for public health intervention and urban planning initiatives targeting socio-economic disparity in ambient air pollution exposure, thus alleviating health disparities across socioeconomic groups.

Race Differences in the Effect of Subjective Social Status on Hostility and Depressive Symptoms Among 9- to 11-Year-Old Children

PURPOSE

Research shows that subjective social status (SSS) is a salient determinant of health. However, there is little research on SSS-related group differences on psychosocial outcomes among children. The purpose of the current study was to determine if associations between psychosocial functioning and SSS in children varied as a function of racial groups.

METHODS

We used a series of regression models to examine associations between SSS and measures of hostility and depressive symptom severity in groups of Black and White children. All analyses controlled for objective markers of family- and neighborhood-level socioeconomic status. Participants included 291 school-age children in Syracuse, NY.

RESULTS

Among Black children, SSS was negatively associated with hostility scores, R2 = 0.10, F(6, 160) = 3.34, p = 0.006, but not depressive symptom severity. Conversely, among White children, SSS was negatively associated with depressive symptom severity, R2 = 0.18, F(6, 117) = 4.37, p = 0.001, but not hostility.

CONCLUSION

These racial differences in SSS-associated psychosocial functioning could be explained by race-based differences in attributions of social mobility and socioeconomic inequalities. Findings provide support for investigating possible tailoring of behavioral interventions to assist children in developing high SSS or coping with low SSS.

Toxic structures: Speculation and lead exposure in Detroit's single-family rental market

Foreclosure sales permitted investors to purchase large volumes of low-cost residential properties after the last financial crisis, reshaping patterns of property ownership in low-income housing markets across the US. This study links post-foreclosure property acquisitions by investor landlords to subsequent lead poisoning cases among children under age six living in Detroit, Michigan. We find that the odds of exhibiting elevated blood lead levels (≥5 μg/dL) are higher for children living in investor-owned homes purchased through tax foreclosure sale. These findings highlight the potential for property speculation in post-foreclosure housing markets to exacerbate severe and racialized burdens of excess lead toxicity in low-income communities.

A global analysis of the regional variation in the symptoms of acute respiratory infection during childhood: Epidemics and their association with environmental vulnerability

Using Demographic and Health Surveys from 48 low-income and middle-income countries (N = 432,860), we investigated whether or not the presence of symptoms of acute respiratory infection (ARI) are contingent on environmental vulnerabilities such as the region, the level of ambient air pollution, community orphanhood status, and household poverty among young children under five. In addition, we also examined whether such an effect may be a consequence of socioeconomic development and/or lifestyle. Using multilevel logistic regression models, environmental vulnerability was found to be significantly associated with the likelihood of childhood ARI symptoms and this association seemed to be related to the level of ambient air pollution. Our findings suggest that important roles are played by both geographic region and ambient air pollution, and that these factors may disproportionately shape a child's risk of ARI symptoms in a global context.

A Roadmap for conducting psychosocial research in epidemiological studies: perspectives of cohort study principal investigators

BACKGROUND

Psychosocial adversity disproportionately affects racial/ethnic and socioeconomic minorities in the USA, and therefore understanding the mechanisms through which psychosocial stress and resilience influence human health can provide meaningful insights into addressing US health disparities. Despite this promise, psychosocial factors are infrequently and unsystematically collected in the US prospective cohort studies.

METHODS

We sought to understand prospective cohort principal investigators' (PIs') attitudes regarding the importance of psychosocial influences on disease aetiology, in order to identify barriers and opportunities for greater inclusion of these domains in high-quality epidemiological research. One-hour, semi-structured qualitative interviews were conducted with 20 PIs representing 24 US prospective cohort studies funded by the National Institutes of Health (NIH), collectively capturing health data on 1.25 of every 100 American adults. A hypothesis-free, grounded theory approach was used to analyse and interpret interview data.

RESULTS

Most cohort PIs view psychosocial factors as an important research area to further our understanding of disease aetiology and agree that this research will be crucial for future public health innovations. Virtually all PIs emphasised that future psychosocial research will need to elucidate biological and behavioural mechanisms in order to be taken seriously by the epidemiological community more broadly. A lack of pertinent funding mechanisms and a lack of consensus on optimal scales and measures of psychosocial factors were identified as additional barriers to advancing psychosocial research.

CONCLUSIONS

Our interviews emphasised the need for: (1) high-quality, longitudinal studies that investigate biological mechanisms and pathways through which psychosocial factors influence health, (2) effort among epidemiological cohorts to broaden and harmonise the measures they use across cohorts, to facilitate replication of results and (3) the need for targeted funding opportunities from NIH and other grant-making institutions to study these domains.

Flaring from Unconventional Oil and Gas Development and Birth Outcomes in the Eagle Ford Shale in South Texas

BACKGROUND

Prior studies suggest exposure to oil and gas development (OGD) adversely affects birth outcomes, but no studies have examined flaring-the open combustion of natural gas-from OGD.

OBJECTIVES

We investigated whether residential proximity to flaring from OGD was associated with shorter gestation and reduced fetal growth in the Eagle Ford Shale of south Texas.

METHODS

We conducted a retrospective cohort study using administrative birth records from 2012 to 2015 (N = 23,487 ) and satellite observations of flaring activity during pregnancy within 5 km of maternal residence. Multivariate logistic and linear regression models were used to estimate associations between four outcomes (preterm birth, small-for-gestational age, continuous gestational age, and term birthweight) and exposure to a low (1-9) or high (≥ 10 ) number of nightly flare events, as compared with no exposure, while controlling for known maternal risk factors. We also examined associations with the number of oil and gas wells within 5 km using data from DrillingInfo (now Enverus).

RESULTS

Exposure to a high number of nightly flare events was associated with a 50% higher odds of preterm birth [odds ratio (OR) = 1.50 (95% CI: 1.23, 1.83)] and shorter gestation [mean difference = - 1.9 (95% CI: - 2.8 , - 0.9 ) d] compared with no exposure. Effect estimates were slightly reduced after adjustment for the number of wells within 5 km . In stratified models these associations were present only among Hispanic women. Flaring and fetal growth outcomes were not significantly associated. Women exposed to a high number of wells (fourth quartile, ≥ 27 ) vs. no wells within 5 km had a higher odds of preterm birth [OR = 1.31 (95% CI: 1.14, 1.49)], shorter gestation [- 1.3 (95% CI: - 1.9 , - 0.8 ) d], and lower average birthweight [- 19.4 (95% CI: - 36.7 , - 2.0 ) g].

DISCUSSION

Our study suggests exposure to flaring from OGD is associated with an increased risk of preterm birth. Our findings need to be confirmed in other populations. https://doi.org/10.1289/EHP6394.

Predicted DRD4 prefrontal gene expression moderates snack intake and stress perception in response to the environment in adolescents

Body weight is substantially determined by eating behaviors, which are themselves driven by biological factors interacting with the environment. Previous studies in young children suggest that genetic influences on dopamine function may confer differential susceptibility to the environment in such a way that increases behavioral obesity risk in a lower socioeconomic status (SES) environment but decreases it in a higher SES environment. We aimed to test if this pattern of effect could also be observed in adolescence, another critical period for development in brain and behavior, using a novel measure of predicted expression of the dopamine receptor 4 (DRD4) gene in prefrontal cortex. In a sample of 76 adolescents (37 boys and 39 girls from Baltimore, Maryland/US, aged 14-18y), we estimated individual levels of DRD4 gene expression (PredDRD4) in prefrontal cortex from individual genomic data using PrediXcan, and tested interactions with a composite SES score derived from their annual household income, maternal education, food insecurity, perceived resource availability, and receipt of public assistance. Primary outcomes were snack intake during a multi-item ad libitum meal test, and food-related impulsivity assessed using a food-adapted go/no-go task. A linear regression model adjusted for sex, BMI z-score, and genetic ethnicity demonstrated a PredDRD4 by composite SES score interaction for snack intake (p = 0.009), such that adolescents who had lower PredDRD4 levels exhibited greater snack intake in the lower SES group, but lesser snack intake in the higher SES group. Exploratory analysis revealed a similar pattern for scores on the Perceived Stress Scale (p = 0.001) such that the low PredDRD4 group reported higher stress in the lower SES group, but less stress in the higher SES group, suggesting that PredDRD4 may act in part by affecting perceptions of the environment. These results are consistent with a differential susceptibility model in which genes influencing environmental responsiveness interact with environments varying in obesogenicity to confer behavioral obesity risk in a less favorable environment, but behavioral obesity protection in a favorable one.

Update in Pediatric Asthma: Selected Issues

Asthma is a complex condition that affects 14% of the world's children and the approach to management includes both pharmacologic as well as non-pharmacologic strategies including attention to complex socioeconomic status phenomena. After an historical consideration of asthma, allergic and immunologic aspects of asthma in children and adolescents are presented. Concepts of socioeconomic aspects of asthma are considered along with environmental features and complications of asthma disparities. Also reviewed are links of asthma with mental health disorders, sleep disturbances and other comorbidities. A stepwise approach to asthma management is discussed that includes pharmacologic and non-pharmacologic strategies in the pediatric population. The role of immunotherapy and use of various immunomodulators are considered as well.

Social Determinants of Pregnancy-Related Mortality and Morbidity in the United States: A Systematic Review

OBJECTIVE

To synthesize the literature on associations between social determinants of health and pregnancy-related mortality and morbidity in the United States and to highlight opportunities for intervention and future research.

DATA SOURCES

We performed a systematic search using Ovid MEDLINE, CINAHL, Popline, Scopus, and ClinicalTrials.gov (1990-2018) using MeSH terms related to maternal mortality, morbidity, and social determinants of health, and limited to the United States.

METHODS OF STUDY SELECTION

Selection criteria included studies examining associations between social determinants and adverse maternal outcomes including pregnancy-related death, severe maternal morbidity, and emergency hospitalizations or readmissions. Using Covidence, three authors screened abstracts and two screened full articles for inclusion.

TABULATION, INTEGRATION, AND RESULTS

Two authors extracted data from each article and the data were analyzed using a descriptive approach. A total of 83 studies met inclusion criteria and were analyzed. Seventy-eight of 83 studies examined socioeconomic position or individual factors as predictors, demonstrating evidence of associations between minority race and ethnicity (58/67 studies with positive findings), public or no insurance coverage (21/30), and lower education levels (8/12), and increased incidence of maternal death and severe maternal morbidity. Only 2 of 83 studies investigated associations between these outcomes and socioeconomic, political, and cultural context (eg, public policy), and 20 of 83 studies investigated material and physical circumstances (eg, neighborhood environment, segregation), limiting the diversity of social determinants of health studied as well as evaluation of such evidence.

CONCLUSION

Empirical studies provide evidence for the role of race and ethnicity, insurance, and education in pregnancy-related mortality and severe maternal morbidity risk, although many other important social determinants, including mechanisms of effect, remain to be studied in greater depth.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42018102415.

The Relationship between Health Disparities, Psychosocial Functioning and Health Outcomes in Pediatric Hematology-Oncology and Stem Cell Transplant Populations: Recommendations for Clinical Care

Not only do racial and ethnic minority children and adolescents with chronic illness experience disparities in health status and health outcomes, they also experience significant healthcare disparities, including differences in healthcare coverage, access to care, and quality of care. It is well known that the interaction between psychosocial functioning, health behaviors and ethnic and racial disparities, ultimately leads to worse health and psychosocial outcomes in pediatric and AYA chronic illness patient populations, including increased rates of morbidity and mortality. Investigating the impact of racial and ethnic factors on health outcomes, and strategies for reducing these disparities, is of the utmost importance, specifically in life-threatening conditions like cancer and sickle cell disease. This commentary underscores the relative importance of identifying factors that could reduce disparities between minority and non-minority populations. This present paper will focus on the dynamic relationships between health disparities, psychosocial factors and health outcomes within pediatric cancer, sickle cell disease and bone marrow transplant populations, and will offer recommendations for healthcare professionals working with these vulnerable patient populations. The primary goal of this commentary is to provide recommendations for enhancing cultural competency and humility for those working with highly vulnerable patient populations.

Eliminating Take-Home Exposures: Recognizing the Role of Occupational Health and Safety in Broader Community Health

Toxic contaminants inadvertently brought from the workplace to the home, known as take-home or paraoccupational exposures, have often been framed as a problem that arises due to unsanitary worker behavior. This review article conceptualizes take-home exposures as a public health hazard by (i) investigating the history of take-home contaminants and how they have been studied, (ii) arguing that an ecosocial view of the problem is essential for effective prevention, (iii) summarizing key structural vulnerabilities that lead populations to be at risk, and (iv) discussing future research and prevention effort needs. This article reframes take-home exposures as one of many chronic pathways that contributes to persistent health disparities among workers, their families, and communities. Including the role of work in community health will increase the comprehensiveness of prevention efforts for contaminants such as lead and pesticides that contribute to environmental disparities.

Health disparities attributable to air pollutant exposure in North Carolina: Influence of residential environmental and social factors

Understanding the environmental justice implications of the mortality impacts of air pollution exposure is a public health priority, as some subpopulations may face a disproportionate health burden. We examined which residential environmental and social factors may affect disparities in the air pollution-mortality relationship in North Carolina, US, using a time-stratified case-crossover design. Results indicate that air pollution poses a higher mortality risk for some persons (e.g., elderly) than others. Our findings have implications for environmental justice regarding protection of those who suffer the most from exposure to air pollution and policies to protect their health.

Ancestry-based intracategorical injustices in carcinogenic air pollution exposures in the United States

Previous studies of US environmental inequalities have focused on racial/ethnic differences in air pollutant exposure. Few have applied an intracategorical framework, which enables the identification of within-group differences through the examination of subgroups. We applied this framework to examine exposure disparities between 26 ancestry/ethnic origin groups within five US racial/ethnic categories. Data come from the US Census, American Community Survey, and National Air Toxics Assessment. We calculated national population-weighted lifetime cancer risk (LCR) scores from residential exposure to hazardous air pollutants. Results showed that Americans of Dominican, Ethiopian, and Somalian descent have the highest total LCR scores at 53.1, 49.2, and 48.3 estimated excess cases of cancer per one million people, respectively. Use of the intracategorical framework enabled characterization of disparate risks that would be overlooked based on the conventional assumption that racial/ethnic environmental inequalities conform to broad, homogenous categories. Intracategorical studies can inform interventions by identifying environmentally-disadvantaged socio-demographic groups.

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

BACKGROUND

A growing body of research has examined relationships between neighborhood characteristics and exposure to air toxics in the United States. However, a limited number of studies have addressed neighborhood isolation, a measure of spatial segregation. We investigated the spatial distribution of carcinogenic air toxics in the St. Louis metropolitan area and tested the hypothesis that neighborhood isolation and sociodemographic characteristics are associated with exposure to carcinogenic air toxics.

METHODS

We obtained lifetime air toxics cancer risk data from the United States Environmental Protection Agency's National Air Toxic Assessment and sociodemographic data from the American Community Survey. We used geographic information systems to identify statistically significant clusters of census tracts with elevated all-site cancer risk due to air toxics in the St. Louis metropolitan area. Relative Risks (RR) were estimated for the association between neighborhood characteristics and air toxic hot spots. Using a local spatial isolation index to evaluate residential segregation, we also evaluated the association between neighborhood racial and economic isolation and air toxic hot spots.

RESULTS

Approximately 14% (85 of the 615) of census tracts had elevated cancer risk due to air toxics (p < 0.01). These air toxic hot spots were independently associated with neighborhoods with high levels of poverty and unemployment and low levels of education. Census tracts with the highest levels of both racial isolation of Blacks and economic isolation of poverty were more likely to be located in air toxic hotspots than those with low combined racial and economic isolation (RR = 5.34; 95% CI = 3.10-9.22).

CONCLUSIONS

These findings provide strong evidence of unequal distribution of carcinogenic air toxics in the St. Louis metropolitan area. Study results may be used to inform public health efforts to eliminate sociodemographic inequalities in exposure to air pollutants.

Masculinity ideology and racism as indicators of obesity risk among Black men

BACKGROUND

Racial inequities in health continue to persist and one major controllable and preventable risk factor is obesity. This study examined whether psychosocial factors such as masculinity ideology and frequency of experiences with racism may be significantly associated with Black men's obesity risk.

METHOD

Participants were 125 Black men aged 20-39 years old (M = 23.0, SD = 3.43). They completed surveys to measure masculinity ideology and experiences with racism. In addition, body mass index, waist-to-hip ratio and systolic and diastolic blood pressure readings were collected. Results showed low negative correlations between experiences with racism and masculinity ideology.

RESULTS

Results showed significant correlations between experiences with racism and masculinity ideology. There were significant interaction effects between masculinity ideology and experiences with racism for body mass index scores, waist-to-hip ratio and blood pressure.

CONCLUSION

Findings indicated that experiences with racism and masculinity ideology interact to impact obesity risk and prevention.

New Toxicology Tools and the Emerging Paradigm Shift in Environmental Health Decision-Making

BACKGROUND

Numerous types of rapid toxicity or exposure assays and platforms are providing information relevant to human hazard and exposure identification. They offer the promise of aiding decision-making in a variety of contexts including the regulatory management of chemicals, evaluation of products and environmental media, and emergency response. There is a need to consider both the scientific validity of the new methods and the values applied to a given decision using this new information to ensure that the new methods are employed in ways that enhance public health and environmental protection. In 2018, a National Academies of Sciences, Engineering, and Medicine (NASEM) workshop examined both the toxicological and societal aspects of this challenge.

OBJECTIVES

Our objectives were to explore the challenges of adopting new data streams into regulatory decision-making and highlight the need to align new methods with the information and confidence needs of the decision contexts in which the data may be applied.

METHODS

We go beyond the NASEM workshop to further explore the requirements of different decision contexts. We also call for the new methods to be applied in a manner consistent with the core values of public health and environmental protection. We use the case examples presented in the NASEM workshop to illustrate a range of decision contexts that have applied or could benefit from these new data streams. Organizers of the NASEM workshop came together to further evaluate the main themes from the workshop and develop a joint assessment of the critical needs for improved use of emerging toxicology tools in decision-making. We have drawn from our own experience and individual decision or research contexts as well as from the case studies and panel discussions from the workshop to inform our assessment.

DISCUSSION

Many of the statutes that regulate chemicals in the environment place a high priority on the protection of public health and the environment. Moving away from the sole reliance on traditional approaches and information sources used in hazard, exposure, and risk assessment, toward the more expansive use of rapidly acquired chemical information via in vitro, in silico, and targeted testing strategies will require careful consideration of the information needed and values considerations associated with a particular decision. In this commentary, we explore the ability and feasibility of using emerging data streams, particularly those that allow for the rapid testing of a large number of chemicals across numerous biological targets, to shift the chemical testing paradigm to one in which potentially harmful chemicals are more rapidly identified, prioritized, and addressed. Such a paradigm shift could ultimately save financial and natural resources while ensuring and preserving the protection of public health. https://doi.org/10.1289/EHP4745.

Community Based Participatory Research (CBPR): A Dynamic Process of Health care, Provider Perceptions and American Indian Patients' Resilience

American Indians are disproportionately affected by factors that lead to health disparities, however many Native people demonstrate resilience when faced with health risks. Study objectives were to use a resilience framework to identify wellness strategies among American Indian people and to assess health care provider perceptions of American Indian wellness. Participants included 39 American Indian adults who self-reported resilient change and 22 health care providers who served American Indian patients. Thematic categories across American Indian and health care provider data were identified: 1) relationships inform resilience; 2) prejudice stymies resilience; and 3) place shapes resilience. Results indicated the salience of relationships in demonstrating resilience. Identified challenges and supporters of resilience are discussed.

Institutional insights on integrating social and environmental science for solutions-driven research

Solving complex environmental problems requires interdisciplinary research involving the social and environmental sciences. The U.S. Environmental Protection Agency is working toward solutions-driven research and interdisciplinary integration within its Office of Research and Development. This article details the history of this process and discusses lessons learned from other federal agencies seeking to integrate social and biophysical research: finding the right combination of top down and bottom up approaches; balancing objectives of advancing science and/or supporting programmatic operations; using social science methods to inform the process; and engaging multiple stakeholders. Attention to the social context of scientific practice, including research processes and research use, fosters success. Three strategies for integrating social sciences to support solutions-driven environmental research are: weaving social science throughout the research process, strengthening social networks, and fostering interdisciplinary hubs. Integration into planning and carrying out research has greater transformative potential than integration into product development and distribution. This article provides insights into institutional considerations for advancing interdisciplinarity and the social context of scientific practice in government agencies. It illustrates the multiple decision contexts and inclusion of social science at the science-policy interface.

The association between the neighbourhood social environment and obesity in Brazil: a cross-sectional analysis of the ELSA-Brasil study

OBJECTIVE

To investigate the association between the neighbourhood social environment, including social cohesion, perceived neighbourhood safety, perceived neighbourhood violence, and obesity in Brazil.

DESIGN

Cross-sectional study.

SETTING

6 state capitals in Brazil (Salvador, Vitoria, Belo Horizonte, Porto Alegre, Sao Paulo and Rio de Janeiro) PARTICIPANTS: Current or former employees of five federal universities and one research centre in each of the six Brazilian state capitals who were participants of the baseline wave (2008-2010) of the Brazilian Longitudinal Study of Adult Health (n=11 456; 56% women; 56% White, 28% Brown, and 16% Black).

PRIMARY OUTCOME MEASURE

Obesity, based on measured weight and height, and defined as having a body mass index ≥30 kg/m².

RESULTS

No associations were found between the neighbourhood social environment and obesity among men. In multilevel logistic regression models adjusted for age, education, skin colour, state of residence, and individual-level social cohesion and perceived violence scores, respectively, women living in the least socially cohesive neighbourhoods and in those perceived as most violent had higher odds of obesity compared with their counterparts (OR=1.25, 95% CI=1.02-1.53; OR=1.28, 95% CI=1.04-1.56, respectively). When stratified by neighbourhood socioeconomic status (SES)-defined based on number of people per household, proportion of children 0-4 years, median income and per cent of white residents at the neighbourhood level-results for social cohesion and for violence remained only for women residing in high SES and low SES neighbourhoods, respectively.

CONCLUSIONS

In this civil-servant sample in six large cities in Brazil, the neighbourhood social environment was associated with obesity among women, but not men. Neighbourhood-level interventions to increase social cohesion and reduce violence may help in the prevention of obesity among women in Brazil.

Could nature help children rise out of poverty? Green space and future earnings from a cohort in ten U.S. cities

BACKGROUND

Growing up in poverty is associated with poor health, and the American Dream of upward mobility is becoming an illusion for many low-income children. But nearby green space can support academic achievement, creativity, and emotional regulation, and these traits might help children rise out of poverty.

OBJECTIVES

To examine the relationship between recent incomes of children born into poverty in the ten largest U.S. cities and densities of residential green space during childhood.

METHODS

We calculate park proximity, park acreage, new park development, and NDVI greenness for 1980-1990 from Landsat and Trust for Public Land data. We obtain the 2014 income for children born between 1978 and 1982 into families in poverty from The Opportunity Atlas cohort, aggregated at the tract level (n = 5849).

RESULTS

Conditional autoregressive (CAR) models of tracts show statistically significant associations between income rank and above-average levels of greenness but not between income rank and park measures, adjusting for individual and neighborhood confounders and spatial autocorrelation. We estimate that, over a 30-year career, children growing up in tracts with the most vegetative cover will earn cumulatively $28,000 more than children growing up in tracts with the least cover, on average. Tracts with lower than average levels of precipitation, higher disadvantage, higher population density, or higher annual temperatures do not show beneficial effects of green space.

CONCLUSIONS

Greenness may be weakly associated with children rising out of poverty in wetter, cooler, less-dense, more advantaged census tracts.

Racialized Structural Vulnerability: Neighborhood Racial Composition, Concentrated Disadvantage, and Fine Particulate Matter in California

This study contributes to previous research by advancing a “racialized structural vulnerability” framework and presenting a new empirical analysis of the relationship between neighborhood Asian, Black, and Latinx composition; extrinsic and intrinsic vulnerability; and PM_2.5 exposures in California with secondary data from 2004–2014. Principal component analyses revealed that tract Latinx composition was highly correlated with extrinsic vulnerability (economic disadvantage and limited English-speaking ability), and that tract Black composition was highly correlated with intrinsic vulnerability (elevated prevalence of asthma-related emergency department visits and low birth weight). Spatial lag regression models tested hypotheses regarding the association between Asian, Black, and Latinx population vulnerability factors and the 2009–2011 annual average PM_2.5 percentile rankings, net of emissions and spatial covariates. Results indicated that the percent Latinx population, followed by the regional clustering of PM_2.5, and the percent of non-Latinx Black and non-Latinx Asian population were the strongest positive multivariable correlates of PM_2.5 percentile rankings, net of other factors. Additional analyses suggested that despite shifting demographic and spatial correlates of 2012–2014 PM_2.5 exposures, the tracts’ Black and Latinx composition and location in the San Joaquin Valley remain important vulnerability factors with implications for future research and policy.

Personal Control of the Indoor Environment in Offices: Relations with Building Characteristics, Influence on Occupant Perception and Reported Symptoms Related to the Building—The Officair Project

Personal control over various indoor environment parameters, especially in the last decades, appear to have a significant role on occupants’ comfort, health and productivity. To reveal this complex relationship, 7441 occupants of 167 recently built or retrofitted office buildings in eight European countries participated in an online survey about personal/health/work data as well as physical/psycho-social information. The relationship between the types of control available over indoor environments and the perceived personal control of the occupants was examined, as well as the combined effect of the control parameters on the perceived comfort using multilevel statistical models. The results indicated that most of the occupants have no or low control on noise. Half of the occupants declared no or low control on ventilation and temperature conditions. Almost one-third of them remarked that they do not have satisfactory levels of control for lighting and shading from sun conditions. The presence of operable windows was shown to influence occupants’ control perception over temperature, ventilation, light and noise. General building characteristics, such as floor number and floor area, office type, etc., helped occupants associate freedom positively with control perception. Combined controlling parameters seem to have a strong relation with overall comfort, as well as with perception regarding amount of privacy, office layout and decoration satisfaction. The results also indicated that occupants with more personal control may have less building-related symptoms. Noise control parameter had the highest impact on the occupants’ overall comfort.

Determinants of per- and polyfluoroalkyl substances (PFAS) in midlife women: Evidence of racial/ethnic and geographic differences in PFAS exposure

BACKGROUND

Per- and poly-fluoroalkyl substances (PFAS) are public health concerns because of widespread exposure through contaminated foods/drinking water. Although some determinants of PFAS exposure have been suggested, the role of geographic location and race/ethnicity in PFAS exposure has not been well characterized.

OBJECTIVES

We examined potential determinants of PFAS from the Study of Women's Health Across the Nation (SWAN).

METHODS

This study includes 1302 women aged 45-56 years from 5 SWAN sites where white women and women from one minority group were recruited (black from Southeast Michigan, Pittsburgh, Boston; Chinese from Oakland; Japanese from Los Angeles). We determined concentrations of 11 PFAS in serum samples collected in 1999-2000 and examined 7 PFAS detected in most women (>97%). Linear regression with backward elimination was used to identify important determinants of PFAS serum concentrations among a set of pre-specified variables (age, body mass index, site, race/ethnicity, education, financial hardship, occupation, born outside the United States (US), parity, menstrual bleeding within the past year, smoking status, alcohol consumption, and consumption of fish, dairy, pizza, salty snack, and French fries).

RESULTS

Site and race/ethnicity were two major determinants of PFAS. White women had higher concentrations of linear perfluorooctanoic acid (PFOA) compared with the Chinese in Oakland (p < 0.0001) and blacks in Pittsburgh (p = 0.048). Black women in Southeast Michigan and Boston (vs. white women) had higher concentrations of linear (p < 0.001 for Southeast Michigan; p < 0.0001 for Boston) and total perfluorooctane sulfonic acid (PFOS) (p < 0.001 for both Southeast Michigan and Boston) and 2-(N-methyl-perfluorooctane sulfonamido) acetic acid (p = 0.02 for Southeast Michigan; p < 0.001 for Boston). Chinese (Oakland) and Japanese (Los Angeles) women had higher concentrations of perfluorononanoic acid (PFNA) compared with white women in each site (p < 0.01 for both). Within white women, those in Pittsburgh had relatively higher concentrations of PFAS. Within Chinese and Japanese women, those who were born outside the US had significantly lower concentrations of most PFAS but significantly higher PFNA concentrations. Menstrual bleeding and parity were significantly associated with lower PFAS concentrations. Higher intake of salty snacks including popcorn was significantly associated with higher concentrations of linear PFOA, PFOS and 2-(N-ethyl-perfluorooctane sulfonamido) acetic acid.

DISCUSSION

Geographic locations and race/ethnicity play an important role in differential exposure to PFAS, with racial/ethnic burdens differing between PFOS, PFOA and PFNA. Menstruation and parity were also determinants of PFAS concentrations possibly as an elimination route.

Psychosocial Stressors, Depression, and Physical Activity among African Americans

Objectives: In this study, we examined how racial discrimination and neighborhood perceptions relate to physical activity and sedentary behavior mediated through depression symptoms. Methods: Data were from the first year of a longitudinal cohort study, Project Creating a Higher Understanding of cancer Research and Community Health (CHURCH), based on a convenience community sample of church-attending African Americans collected between April 2012 and March 2013 (N = 370) in Houston, Texas. Measures included racial discrimination, perceived neighborhood problems and vigilance, depression (CES-D), physical activity (IPAQ-short), and sedentary behavior. Results: Main effects from the structural equation model showed that racial discrimination (b = .20, p < .01) was related to greater depression symptoms. The same pattern emerged for neighborhood problems, but the effect was not significant (b = .20, p = .07). Further, depression symptoms were related to less physical activity (b = -.62, p = .03) and greater sedentary behavior (b = .64, p < .01). Indirect effects showed that depression mediated the relationship between racial discrimination and neighborhood problems on physical activity and sedentary behavior. Conclusions: Depression symptoms are an important mechanism by which racial discrimination and perceived neighborhood problems impact physical activity and sedentary behavior.

Developing a Policy Brief on Child Mental Health Disparities to Promote Strategies for Advancing Equity among Racial/Ethnic Minority Youth

Research has identified a broad range of risk factors during early childhood that have neurobiological consequences and negatively affect children's mental health. Such risk factors disproportionately affect racial/ethnic minority youth. Disparities in children's mental health service use have also been documented for minority youth. Yet, compared with the focus on strategies to address health disparities (including mental health disparities) during adulthood, very little work has concentrated on addressing the roots of health disparities that occur in childhood. The purpose of this commentary is to describe the development and dissemination of a policy brief for policy advocates. The goal of this work is to help achieve the implementation of evidence-based programs, practices, and policies that target and modify risk factors to reduce disparities in child mental health burden.

Community-Based Participatory Research at Jacksonville Florida Superfund Ash Site: Toxicology Training to Improve the Knowledge of the Lay Community

Until the late 1960's, Jacksonville, Florida incinerated its solid waste with the resultant ash deposited in landfills or used to fill flood-prone areas. These filled areas were later developed into parks, school sites and residential areas. Lead in soil at these sites was the major toxicant of concern and driver of clean-up actions. During the period of assessment of lead-levels in soil, there were no established lines of communication between the City and residents of affected neighborhoods resulting in mistrust in the community. To address communication issues, a community-based, culturally sensitive Community Environmental Toxicology Curriculum (CETC) and a short video were developed for community stakeholders to inform them of risks, health effects, remediation processes and preventive measures. Pre-and post-tests were developed to measure knowledge gained from the toxicology training. Learning gains averaged 47% and 24% for the community leaders and residents respectively. Most participants strongly agreed that the community toxicology curriculum was a useful tool for promoting awareness of environmental risks in their community and addressing the gap in trust between residents and agencies involved in site remediation.

Hybrid Resiliency-Stressor Conceptual Framework for Informing Decision Support Tools and Addressing Environmental Injustice and Health Inequities

While structural factors may drive health inequities, certain health-promoting attributes of one's "place" known as salutogens may further moderate the cumulative impacts of exposures to socio-environmental stressors that behave as pathogens. Understanding the synergistic relationship between socio-environmental stressors and resilience factors is a critical component in reducing health inequities; however, the catalyst for this concept relies on community-engaged research approaches to ultimately strengthen resiliency and promote health. Furthermore, this concept has not been fully integrated into environmental justice and cumulative risk assessment screening tools designed to identify geospatial variability in environmental factors that may be associated with health inequities. As a result, we propose a hybrid resiliency-stressor conceptual framework to inform the development of environmental justice and cumulative risk assessment screening tools that can detect environmental inequities and opportunities for resilience in vulnerable populations. We explore the relationship between actual exposures to socio-environmental stressors, perceptions of stressors, and one's physiological and psychological stress response to environmental stimuli, which collectively may perpetuate health inequities by increasing allostatic load and initiating disease onset. This comprehensive framework expands the scope of existing screening tools to inform action-based solutions that rely on community-engaged research efforts to increase resiliency and promote positive health outcomes.

Social Inequalities in Environmental Resources of Green and Blue Spaces: A Review of Evidence in the WHO European Region

Residential green and blue spaces and their potential health benefits have received increasing attention in the context of environmental health inequalities, because an unequal social distribution of these resources may contribute to inequalities in health outcomes. This systematic review synthesised evidence of environmental inequalities, focusing on availability and accessibility measures of green and blue spaces. Studies in the World Health Organisation (WHO) European Region published between 2010 and 2017 were considered for the review. In total, 14 studies were identified, where most of them (n = 12) analysed inequalities of green spaces. The majority had an ecological study design that mostly applied deprivation indices on the small area level, whereas cross-sectional studies on the individual level mostly applied single social measures. Ecological studies consistently showed that deprived areas had lower green space availability than more affluent areas, whereas mixed associations were found for single social dimensions in cross-sectional studies on the individual level. In order to gain more insights into how various social dimensions are linked to the distribution of environmental resources within the WHO European Region, more studies are needed that apply comparable methods and study designs for analysing social inequalities in environmental resources.

Climate Change, Human Health, and Social Stability: Addressing Interlinkages

BACKGROUND

Abundant historical evidence demonstrates how environmental changes can affect social stability and, in turn, human health. A rapidly growing body of literature, largely from political science and economics, is examining the potential for and consequences associated with social instability related to current climate change. However, comparatively little of this research incorporates the effects on human health or the role of health systems in influencing the magnitude and types of instability that could occur.

OBJECTIVE

The objective of this commentary is to articulate a conceptual framework incorporating health outcomes and health systems into theorized and observed linkages between climate change and social instability, illustrating in particular the health effects of natural resource shortages, infectious disease outbreaks, and migration.

DISCUSSION

Although increasing evidence exists that climate change, health, and social instability are related, key questions remain about the pathways linking these factors, as well as the magnitude, causality, and directionality of relationships across spatial and temporal scales. Models seeking to explain and predict climate-related social unrest should incorporate the many linkages between climate change, human health, and social instability. Members of the environmental health research community should work closely with those in the political science and economics communities to help deepen understandings of climate-related stressors and shocks that affect instability and worsen health outcomes. https://doi.org/10.1289/EHP4534.

Social and Environmental Neighborhood Typologies and Lung Function in a Low-Income, Urban Population

Consensus is growing on the need to investigate the joint impact of neighborhood-level social factors and environmental hazards on respiratory health. This study used latent profile analysis (LPA) to empirically identify distinct neighborhood subtypes according to a clustering of social factors and environmental hazards, and to examine whether those subtypes are associated with lung function. The study included 182 low-income participants who were enrolled in the Colorado Home Energy Efficiency and Respiratory Health (CHEER) study during the years 2015⁻2017. Distinct neighborhood typologies were identified based on analyses of 632 census tracts in the Denver-Metro and Front Range area of Colorado; neighborhood characteristics used to identify typologies included green space, traffic-related air pollution, violent and property crime, racial/ethnic composition, and socioeconomic status (SES). Generalized estimating equations were used to examine the association between neighborhood typology and lung function. We found four distinct neighborhood typologies and provide evidence that these social and environmental aspects of neighborhoods cluster along lines of advantage/disadvantage. We provide suggestive evidence of a double jeopardy situation where low-income populations living in disadvantaged neighborhoods may have decreased lung function. Using LPA with social and environmental characteristics may help to identify meaningful neighborhood subtypes and inform research on the mechanisms by which neighborhoods influence health.

Examining the Association between Socioeconomic Status and Exposure to Carcinogenic Emissions in Gyeonggi of South Korea: A Multi-Level Analysis

Although South Korea introduced the Pollutant Release and Transfer Register system in 1996, there is relatively limited evidence on how socioeconomic status at both individual and municipal levels is associated with exposure to toxic chemicals in Korea because of limited data sources. Using a multi-level negative binomial model, this study examined the socioeconomic status of both individuals and municipalities with a higher level of exposure to carcinogenic emissions from industrial facilities in Gyeonggi province, South Korea. The results reveal that economic minority individuals (national basic livelihood security recipients, unemployed people, and tenants), municipalities with higher percentages of industrial land use, and foreign-born populations had more facilities that produce carcinogenic emissions. While similar findings have been reported by many environmental justice studies conducted in other countries, this is the first Korean case study that reports the relationship between socioeconomic status at both individual and municipal levels and exposure to toxic chemicals.

The State of Public Health Lead Policies: Implications for Urban Health Inequities and Recommendations for Health Equity

Although lead has been removed from paint and gasoline sold in the U.S., lead exposures persist, with communities of color and residents in urban and low-income areas at greatest risk for exposure. The persistence of and inequities in lead exposures raise questions about the scope and implementation of policies that address lead as a public health concern. To understand the multi-level nature of lead policies, this paper and case study reviews lead policies at the national level, for the state of California, and for Santa Ana, CA, a dense urban city in Southern California. Through a community-academic partnership process, this analysis examines lead exposure pathways represented, the level of intervention (e.g., prevention, remediation), and whether policies address health inequities. Results indicate that most national and state policies focus on establishing hazardous lead exposure levels in settings and consumer products, disclosing lead hazards, and remediating lead paint. Several policies focus on mitigating exposures rather than primary prevention. The persistence of lead exposures indicates the need to identify sustainable solutions to prevent lead exposures in the first place. We close with recommendations to reduce lead exposures across the life course, consider multiple lead exposure pathways, and reduce and eliminate health inequities related to lead.

Environmental Justice in Industrially Contaminated Sites. A Review of Scientific Evidence in the WHO European Region

In the WHO European Region the topic of contaminated sites is considered a priority among environment and health themes. Communities living in or close to contaminated sites tend to be characterized by a high prevalence of ethnic minorities and by an unfavorable socioeconomic status so rising issues of environmental justice. A structured review was undertaken to describe the contents of original scientific studies analyzing distributive and procedural justice in industrially contaminated sites carried out in the WHO European Region in the period 2010⁻2017. A systematic search of the literature was performed. In total, 14 articles were identified. Wherever assessments on environmental inequalities were carried out, an overburden of socioeconomic deprivation or vulnerability, with very few exemptions, was observed. The combined effects of environmental and socioeconomic pressures on health were rarely addressed. Results show that the studies on environmental and health inequalities and mechanisms of their generation in areas affected by industrially contaminated sites in the WHO European Region are in their early stages, with exemption of UK. Future efforts should be directed to improve study strategies with national and local assessments in order to provide evidence for equity-oriented interventions to reduce environmental exposure and related health risks caused by industrial contamination.

Gene-environment interactions in Alzheimer's disease: A potential path to precision medicine

Alzheimer's disease (AD) is the leading cause of dementia in the United States and afflicts >5.7 million Americans in 2018. Therapeutic options remain extremely limited to those that are symptom targeting, while no drugs have been approved for the modification or reversal of the disease itself. Risk factors for AD including aging, the female sex, as well as carrying an APOE4 genotype. These risk factors have been extensively examined in the literature, while less attention has been paid to modifiable risk factors, including lifestyle, and environmental risk factors such as exposures to air pollution and pesticides. This review highlights the most recent data on risk factors in AD and identifies gene by environment interactions that have been investigated. It also provides a suggested framework for a personalized therapeutic approach to AD, by combining genetic, environmental and lifestyle risk factors. Understanding modifiable risk factors and their interaction with non-modifiable factors (age, susceptibility alleles, and sex) is paramount for designing personalized therapeutic interventions.

Residential Segregation and Racial/Ethnic Disparities in Ambient Air Pollution

Race and ethnicity are consequential constructs when it comes to exposure to air pollution. Persistent environmental racial/ethnic inequalities call for attention to identifying the factors that maintain them. We examined associations between racial residential segregation and racial/ethnic inequalities in exposure to three types of air pollutants. Using data from the Panel Study of Income Dynamics (1990-2011), the U.S. Census (1990- 2010), and the Environmental Protection Agency, we tested the independent and joint contributions of race/ethnicity and metropolitan-level residential segregation on individual levels of exposure to air pollution nationwide. We found that racial and ethnic minorities were exposed to significantly higher levels of air pollution compared to Whites. The difference between minorities and Whites in exposure to all three types of air pollution was most pronounced in metropolitan areas with high levels of residential segregation. The environmental inequities observed in this study call for public health and policy initiatives to ameliorate the sources of racial/ethnic gaps in pollution exposure. Given the links between the physical environment and health, addressing such uneven environmental burdens may be a promising way to improve population health and decrease racial/ethnic inequalities therein.