Reporting individual results for biomonitoring and environmental exposures: lessons learned from environmental communication case studies

Measurement methods for chemicals in biological and personal environmental samples have expanded rapidly and become a cornerstone of health studies and public health surveillance. These measurements raise questions about whether and how to report individual results to study participants, particularly when health effects and exposure reduction strategies are uncertain. In an era of greater public participation and open disclosure in science, researchers and institutional review boards (IRBs) need new guidance on changing norms and best practices. Drawing on the experiences of researchers, IRBs, and study participants, we discuss ethical frameworks, effective methods, and outcomes in studies that have reported personal results for a wide range of environmental chemicals. Belmont Report principles and community-based participatory research ethics imply responsibilities to report individual results, and several recent biomonitoring guidance documents call for individual reports. Meaningful report-back includes contextual information about health implications and exposure reduction strategies. Both narrative and graphs are helpful. Graphs comparing an individual’s results with other participants in the study and benchmarks, such as the National Exposure Report, are helpful, but must be used carefully to avoid incorrect inferences that higher results are necessarily harmful or lower results are safe. Methods can be tailored for specific settings by involving participants and community members in planning. Participants and researchers who have participated in report-back identified benefits: increasing trust in science, retention in cohort studies, environmental health literacy, individual and community empowerment, and motivation to reduce exposures. Researchers as well as participants gained unexpected insights into the characteristics and sources of environmental contamination. Participants are almost universally eager to receive their results and do not regret getting them. Ethical considerations and empirical experience both support study participants’ right to know their own results if they choose, so report-back should become the norm in studies that measure personal exposures. Recent studies provide models that are compiled in a handbook to help research partnerships that are planning report-back. Thoughtful report-back can strengthen research experiences for investigators and participants and expand the translation of environmental health research in communities.


Discussion
As more teams experiment with report-back, their experiences create a track record to inform ethical decisions and best practice methods.
Ethics: weighing potential benefits as well as harms As a starting point for ethical considerations, the 1979 Belmont Report, which established the basic ethical framework for modern biomedical research in the U.S., calls on researchers to avoid harm and maximize beneficence, autonomy, and justice [15]. These standards have sometimes been interpreted to weigh against reporting for emerging contaminants, because of concerns that participants cannot benefit if results have uncertain clinical health implications and might be harmed by excessive worry about their exposures. However, in environmental public health, the potential benefits often occur outside of clinical care, and decisions rely on animal and limited epidemiologic evidence, because these are the best resources available. In this context, beneficence can encompass giving participants opportunities to learn about the strengths and weaknesses of the science in order to make their own decisions about their results, and autonomy and justice also reinforce the participant's right-to-know their results in order to act on them [16]. For example, participants may choose to reduce exposures as a precaution or to become engaged in public discourse about chemical use and regulation. From an evidence-based perspective, although researchers and IRBs often focus on the possibility of creating alarm [17], we have not observed this in our studies or other studies familiar to us [12,18,19].
Additional ethical concerns have been raised about reporting results when there is uncertainty in the exposure measurements themselves. For example, one-time assessments may not be representative of exposure to some chemicals, and this limitation should be explained.
The ethical framework for community-based participatory research (CBPR) offers an additional perspective that deemphasizes clinical medicine and emphasizes community impact [20]. CBPR conceptualizes research as a joint effort of researchers, community members, and study participants. It values mutual respect, open communication, shared decision-making, co-ownership of data, and empowerment [21]. This perspective highlights the potential of report-back to inform and empower constructive action to improve public health. In addition, CBPR considers the rights of research communities, not just individuals, particularly regarding the potential for stigma or economic harm [16,17]. A key question in CBPR report-back is whether and how participants and communities want to receive their results. In studies that have asked participants, nearly all do want to know [11,19,22,23].

Informed consent
With an eye toward autonomy, we think that ethical methods give participants a right to know or not know their exposure results. The decision about whether to receive results can be integrated into informed consent as a logical extension of this practice, which arose after past ethical abuses led to requirements for researchers to inform participants about the research protocol and its risks and benefits. Informed consent provides an early opportunity to set expectations about what participants will and won't be able to learn from their results and ask about their choice. For example, the Three Generations Study (a study of the daughters and granddaughters of women enrolled when they gave birth in Oakland, CA, in 1959CA, in -1967 explains: These results are not designed for medical use and the information you receive may not suggest any actions you can take to reduce your health risk or exposure to these compounds. However, if you do choose to receive these results we will provide you with as much information as we can and will refer you to available resources to help you understand them (Public Health Institute 2012, unpublished G2 consent form).
Legal issues should be addressed. For example, in rare circumstances, a participant who learns about household contaminants might be obligated to disclose those results prior to a home sale. Requirements may apply to regulated contaminants, such as lead, but few chemicals are regulated.

Designing report-back
Decisions about the content of personal exposure reports can benefit from input from study participants and communities, and they can draw from a growing number of field-tested models. Literatures on risk communication, data visualization, science and health literacy, numeracy, and broader cognitive and social science fields also inform and improve report-back methods. The Report-back Handbook includes examples of text and graphs, and references to evaluations using focus groups or interviews with participants that give confidence in effectiveness. Examples of evaluation methods are included.
We have found that personal exposure reports should answer these basic questions: What did you find? How much? Where did it come from? Is it safe? What should I do? [16]. To make results meaningful, personal reports should explain what is known about health implications and exposure reduction, including both individual and communitylevel or national actions. This information can include discussions relevant to a particular study, for example addressing toxicity pathways, potential effects of mixtures, and strengths or gaps in government safety standards.
Reports should include both text and graphs, because different people respond better to different forms of communication. Researchers frequently assume that graphs will not be understood in communities with low numeracy, but, on the contrary, well-designed graphs can draw on hard-wired visual capacities to judge differences and relationships [24]. When we give participants results graphs, we find that even some who think the graphs will be "too hard" begin to read and interpret them, thinking aloud about their meaning.
Comparative data can help participants interpret their results. Comparisons may include government guidelines, if they are available, results for other study participants, and percentile levels from the National Health and Nutrition Examination Survey (NHANES) [25]. Figure 1 illustrates results for an individual in comparison with others in the study and a government health guideline.
To set expectations, researchers can explain that everyday chemicals are commonly detected and that detecting a chemical does not necessarily imply a health risk. For example, the Metals Exposure Study in Homes (MESH) study of exposures near mining sites tells participants, "MESH is designed to measure individual exposures to metals in the environment. It is not attempting to explain the relationship between an exposure and a health outcome" (University of Arizona 2013, unpublished results packet). However, participants can benefit from learning what scientists do know and what potential health concerns led them to select a chemical to measure. For example, the Cape Cod Household Exposure Study fact sheet says: Other chemicals were chosen for this study because of evidence that they may affect hormones. Some of these chemicals mimic estrogen. They are found in common products, including some pesticides, cleaning products, plastics, furniture, and cosmetics. Exposure to the natural estrogen made in our bodies increases breast cancer risk, so learning about exposure to other chemicals that mimic estrogen may one day help us learn ways to prevent breast cancer [14].
The timing as well as content of report-back is important. Participants want to receive results promptly and to hear from researchers before they hear second hand through the media. On the other hand, researchers are reluctant to release findings prior to revisions that may result from peer review. The C8 Study (a study of perfluorooctanoic acid in residents affected by industrial contamination of drinking water from the Ohio River) resolved these dilemmas by developing a Community-First Model for reporting results after peer-review but before publication. The study developed a precisely timed sequence of communications to study participants, medical providers, news media, and the community [26]. News media reports and community meetings can support and augment individual report-back when these efforts are well-coordinated.
In small studies or studies where researchers are collecting repeat samples, participants can benefit from in-person reports. Studies have also successfully sent results by mail, and we are currently developing interactive online methods to personalize results in large studies, so that people can navigate to results of interest to them and control the level of detail. In any case, a researcher should be available to answer questions or to phone participants with unusual measurements.
In studies that actively invite participants to decide whether to receive their results, nearly all choose to do so. Other studies have required participants to contact the study team to request their report. This method appears to be a barrier to access and may not ensure that all participants who want their results will get them [17,19].

Experiences from the field
The report-back approaches we describe have been adopted in a variety of settings, including low-income and immigrant communities. We have written about interviews with participants and researchers [12,17,18], and we are analyzing interviews from additional studies. Here we summarize themes from interviews and small-group discussions in multiple settings in order to give researchers considering report-back a sense of what to expect.

Participants were not excessively worried
Our first concern was to assess whether participants were unduly worried by their results and the scientific uncertainties associated with them. In the studies we have examined, where researchers prepared reports with care to make them understandable and meaningful, participants have been grateful for their results and worries were kept in perspective. Participants were often surprised to learn that their bodies harbor chemicals from everyday consumer products, pollution, and even chemicals banned years ago, but they quickly began assimilating information and thinking about its meaning and solutions.
Participants learned about environmental health and some took steps to reduce exposures Personal exposure report-back is a powerful tool for increasing understanding of environmental health. In the Household Exposure Study [12], as well as other studies we are analyzing now, people often thought initially that military and industrial facilities were the major source of contaminants and learned from their results that chemical exposures can come from everyday consumer products, such as furniture, cleaners, cosmetics, and pesticides, purchased recently or lingering from years ago. A mother whose daughter was tested as part of the Cohort of Young Girls' Nutrition, Environment, and Transitions (CYGNET) Study (a San Francisco Bay Area cohort study of puberty in girls) describes her changed awareness: I really thought I was lily white and pure…but all of a sudden I read, "we detected 19 chemicals in your daughter's urine, ' and I'm like… I have residues from insecticides and disinfectants and mothballs, and…I realized it's from fragrances and soaps and detergents and things [14].
Participants began thinking about possible sources of chemicals in their bodies and homes, and strategies to reduce exposure Those who had already tried to be "green" shoppers considered the limits of individual actions for avoiding exposures and began asking questions about the role of government [18]. Strip plots like this one have been used effectively to communicate to participants about their own results in comparison with others in the same study, a health guideline, and other benchmarks, such as NHANES results. This graph format has been evaluated in focus groups and one-on-one usability tests and interviews, including in low-income and recent-immigrant communities. Well-designed graphs have the advantage of drawing on innate visual abilities, relying less on numeracy and literacy.
Many express intentions to change their exposures, and some describe changes they actually made. Follow-up to evaluate the extent to which report-back generates lasting change is an important avenue for future study. Changes could be in individual behavior or at the community level, as illustrated by this participant in the Household Exposure Study who decided to attend a public meeting about emissions from a nearby refinery: At first I was thinking, 'God, I wish I didn't know all this.' But the more I think about it, the more I understand it, the more I feel like it helps me to…to try to do whatever I can to mitigate or alleviate the toxins that are in my environ-ment…If you don't know the information, then you have an excuse for not being active. But if you know the information, then you can't not participate in trying to make change [18].
Participants felt respected and grateful, and saw their contribution to science in a brighter light Another consistent theme from participant interviews is gratitude for researchers' time, attention, and honesty. Perhaps because the results are complex and uncertain, participants felt respected and more trusting of researchers. After seeing their results, participants understood better their own contribution to knowledge and to future health solutions.

Researchers found report-back demanding but beneficial
Researchers found the process intellectually challenging and time-consuming, and were concerned that it required skills beyond their expertise. However, they were glad they had done it. Their anticipatory fears that people would be alarmed were not realized. Researchers conducting cohort studies found the process strengthened relationships and commitment to participation.
Benefits for research, environmental health literacy, and civil society While we take a "rights" perspective on why researchers should report individual results, we also see benefits for the researchers themselves and for the standing of science in society. Researchers benefit because the report-back process strengthens relationships with participants and can support recruitment, retention, and trust in science. Report-back also can influence the researchers' own thinking and public understanding of the science as well. While researchers generally focus on statistical measures of central tendency and relationships across distributions, report-back draws attention to outliers, which can lead to different kinds of discovery. When we prepared the individual reports for the Household Exposure Study, for example, we noted two individuals whose polychlorinated biphenyl (PCB) house dust levels were exceptionally high. Knowing that we would be talking to those participants motivated us to re-test their dust, collect blood samples, inspect the homes, and interview the residents in search of an explanation. We discovered that a floor finish was a likely source in these homes and a widespread, previously neglected source in older homes in general [27]. Extreme exposures, even in a midsized study, can represent a substantial number of people if those outliers represent an exposure scenario that is generalizable to the US population, so communicating with participants in these contexts can inform targeted public health interventions.
In addition to generating novel discoveries, report-back stimulates trans-disciplinary and integrative thinking that can help researchers develop the translational aspects of their findings. Writing the interpretive text for reports requires researchers to synthesize what is known about biological and human health effects of chemicals, and chemical sources, fate in the environment, and exposure pathways.
In the public sphere, as individuals learn their own exposure results and share them with family, friends, doctors, and public leaders, we envision the potential to raise the civic discourse about environmental public health. In a democratic society, data that make the invisible residues of consumer products and pollution known to the affected individuals and communities can empower them to make decisions about research funding, public policies, and their own behavior.

Future needs
Experiences with reporting individual results have been positive, but researchersboth those who have reported results and those who have notidentify important needs. Concerns about resources and expertise for report-back are at the top of the list. To make report-back practical, researchers need access to models that can be adapted in diverse study settings. Our Report-back Handbook (see Additional file 3) is a starting point for creating a library of methods that researchers and community partners can adapt to their own studies. Sharing, building upon, and continually improving these resources will make report-back easier and encourage broader use of field-tested methods.
Improved IRB training in human research ethics for CBPR and, specifically, report-back ethics could also reduce delays and constraints that can unintentionally undermine participants' trust in research and the effectiveness of report-back [28]. For example, IRBs need strategies that guide report-back without approval of every iteration, which can interfere with the natural back-and-forth between researchers and participants as they design reportback that is responsive to a particular community and address questions that arise. Researchers also need training in report-back methods and evaluation techniques, for example, through webinars and consultations with experienced practitioners.  22 Table 2. Report-back information that helps answer typical participant questions.
24 Figure 1. Examples of guides that can be used as a roadmap for interpreting graphical presentations of individual exposure data, data from other participants, national averages, and benchmarks. a) A guide from the Northern California Household Exposure Study. b) A guide from the Chemicals in Our Bodies Study. 32 Figure 6. Reports in the Cape Cod Drinking Water Study used colors to show contaminant levels above natural background levels or above a guidance level. 33 Figure 7. Box plots comparing levels of fine particulate matter (PM 2.5 ) in two study communities in the Northern California Household Exposure Study. These aggregate results can also be compared to benchmarks to provide additional context for interpreting results.
34 Figure 8. Strip plots comparing levels of fine particulate matter (PM 2.5 ) in two study communities in the Northern California Household Exposure Study.
35 Figure 9. A cumulative bar graph comparing the number of compounds detected in outdoor air in two study communities in the Northern California Household Exposure Study.
36 Figure 10. Strip plot reporting individual blood serum levels of PFOA relative to other study participants and the national average in the Growing up Female Study (Hernick 2007).
37 Figure 11. Graph reporting average blood serum levels of PFOA for two study communities relative to workers with high exposure, the national average, and a sample from the San Francisco Bay area (Growing up Female Study) (Hernick 2007). 41 Figure 12. Recommendation for further research or action should be calibrated to reflect the level of certainty in knowledge about health effects and exposure reduction methods (Brody 2007).
At the beginning of a study, researchers can explain to participants what they willand won't -be able to learn from the results, so they can decide whether they want to receive their own report. WWW.SILENTSPRING.ORG Here's our top advice for reporting personal exposure results in a CBPR context.  Yet early exposure measurements often outpace our understanding of the health implications and strategies for reducing exposures. The 2006 National Academy of Sciences (NAS) report Human Biomonitoring for Environmental Chemicals noted that as new technologies measure lower concentrations of larger numbers of chemicals, new challenges arise about how to interpret, report, and act on results that only partially illuminate the links between environmental chemicals and health (National Academy of Sciences 2006).
Decisions about whether and how to report study results to participants must weigh two dimensions. On one dimension, report-back may motivate behavior change and protective public health policies, increase trust in and understanding of research, and respect participants' autonomy. On the other dimension, there is potential for harm, for example, from worry, stigma, or ineffective action to reduce exposures.
A growing number of study teams are deciding that participants have a right to know their individual results if they want them, but there is little information about how to report results ethically and effectively. The NAS report recommended sharing information about multiple approaches in order to develop best practices. There's been a catch-22, though, because some IRBs have been reluctant to allow development of individual report-back alternatives. Perhaps these decision-makers are not aware of successful examples of individual-level report-back.
This handbook aims to address this information gap about report-back practices by sharing the lessons learned by our team, beginning from the Household Exposure Study (HES), an ongoing study of exposures to endocrine disrupting compounds (EDCs) in homes. The HES team is an interdisciplinary collaboration led by Silent Spring Institute with partners at Communities for a Better Environment, Brown University, Northeastern University, the University of California, Berkeley, Commonweal, and the Harvard Law School Emmett Environmental Law and Policy Clinic. This handbook draws on our experience reporting community and individual results, and interviewing participants about their experiences after they received their reports. We also incorporate our observations and interviews in the studies that are part of our National Institute of Environmental Health Sciences (NIEHS)-funded Personal Exposure Report-back Ethics (PERE) Study, and we draw on our day-long workshop of 40 researchers, study participants, IRB representatives, and state and federal agency officials. Our goal is to help guide other study teams, including researchers, advocates, IRB members, and public health officials through decisions on whether and how to report study findings to participants.
As more teams begin reporting individual exposure results, we hope to share additional experiences and perspectives. Please send comments, questions, and examples of report-back materials to brody@silentspring.org.
When study participants learn that their personal exposures can be linked to everyday products like make-up, they have an opportunity to change their actions to reduce exposures.

PLANNING AHEAD
Effective report-back begins with planning and communication. One of the first steps is to bring together researchers, community leaders, participants, and other stakeholders to identify communication needs and goals. Getting started early in the research process can help teams ensure that they allocate time and resources and anticipate roadblocks. The National Institute of Environmental Health Sciences (NIEHS) is even beginning to encourage researchers to address these issues in proposed data sharing plans.
This chapter helps teams get started, including deciding whether to report individual results, resource requirements, and team member responsibilities. It includes a discussion of incorporating the report-back plan into the informed consent and tips for working with Institutional Review Boards (IRBs).

DECIDING WHETHER TO REPORT
Should researchers report individual results, including in studies testing for chemicals for which sources of exposure, health effects, and exposure reduction strategies are uncertain? The ethical principles of human subjects research (box) are a helpful jumping off point for answering that question.

Ethical principles
The ethical principles of autonomy and justice favor reporting individual results. The principle of autonomy directs researchers to provide individuals with the opportunity to decide freely if they wish to become study participants. Extending that principle to communicating results, it follows that study participants have a right to know or not know their individual study results as a basis for self-determination in taking action, for example by making personal changes to reduce exposures or by supporting protective public health policies.
Beneficence guides researchers to consider benefits, such as the potential for results reporting to inform and motivate individuals and communities to take actions to reduce exposures, protect their health, and participate more fully in public health research and policy. Nonmalfeasance guides researchers to avoid harm, such as the potential for report-back to cause fear, worry, or stigma; legal and economic com- plications, such as effects on health insurance or property values; and the possible unintended promotion of unnecessary or counter-productive interventions. The principle of justice includes the responsibility to provide equitable access to the potential benefits of research. Sharing results with participants not only disseminates knowledge that can inform decisions about exposure reduction, it can also address disparities in access to knowledge.
We identified three ethical frameworks that have been used to make decisions about reporting individual results in personal exposure studies. Each gives varying weight to the ethical principles of human subjects research: • Clinical medicine -an expert-driven approach, which has historically supported reporting results only when the health significance of exposures is known gives priority to preventing harm from worry, • Community-based participatory research (CBPR) -a prevention-oriented approach, which emphasizes autonomy in participants' right to decide whether to learn their results and beneficence in the potential to inform constructive action even when health effects are uncertain, and • Citizen-science data judo -an advocacy-driven approach, which encourages reporting individual results to support precautionary action and policy change (Brody 2007; Morello-Frosch 2009; Morello-Frosch 2005).
We believe that the best interpretation of ethical values weighs in favor of a participant's right to decide whether to know or not know individual results. At present, though, only the California biomonitoring program requires report-back, so choices about whether to report remain with researchers and IRBs.

CBPR approaches consider community and participant views, support health-protective action, and build trust
We adopted a CBPR framework, which values mutual respect and open communication, co-ownership of data, and empowerment (Brody 2007). This handbook reflects our CBPR approach.
The CBPR framework emphasizes that reporting study results can benefit participants and communities by creating access to information and empowering people to act on that information. Because reporting individual results has the potential to negatively impact communities-through stigmatization, for example-CBPR considers the rights of both individuals and communities. A CBPR approach involves collaborative decision making among researchers, study participants, and community members. Just as researchers and participants enter into a relationship to conduct the research, that relationship extends to the report-back process.
A key question, then, is whether the study community and participants want their results. Experience in studies that have asked their participants show that most do want to know (Brown-Williams 2009a; Nelson 2009; Quandt 2004; Wu 2009). For example, in our Household Exposure Study (see box), community leaders advocated for reporting individual results to participants who wanted them, despite uncertainty about the health effects of many of the contaminants measured (Brody 2007). Nearly all participants requested their results, and follow-up interviews with participants indicate that they appreciated the opportunity to receive them (Altman 2008;Brody 2007). One study participant noted: At first I was thinking, "God, I wish I didn't know all this." But the more I think about it, the more I understand it, the more I feel like it helps me to, … do whatever I can…if you know the information then you can't not participate in trying to make change. In the CYGNET Study, one of the NIEHS Breast Cancer and the Environment Research Centers (BCERC), all but one of the parents expressed an interest in learning their daughters' results, even if they expressed concern about the potential implications (Brown-Williams 2009b).
A study of pesticide exposures in the homes of farmworkers in North Carolina followed a CBPR approach to communicating results, emphasizing participants' right-toknow the information (Quandt 2004). Informal interviews with participants and more structured interviews with community members about what they thought participants would want to know supported reporting individual results. The researchers argued that participants in this and other community-based research studies should receive their results because "It is ethical to return information to the 'owner' of that information." They note that sharing information builds trust among researchers, participants, and communities.
Our interviews with researchers and study participants indicate a trend in favor of communicating results to participants (Adams 2011; Altman 2008; Morello-Frosch 2009). Indeed, a growing number of personal exposure and biomonitoring studies are reporting individual results, while others are considering reporting or are in the planning phase. Examples of studies that have reported individual results are shown in Table 1.

ANTICIPATING THE COSTS
Implementing a communication plan can be time-intensive. Don't forget to allocate time for interpreting data, developing and disseminating materials, answering participants' questions, and maintaining regular communications with the study community. Some studies need funds for translating materials into multiple languages. Build these

HOUSEHOLD EXPOSURE STUDY
Silent Spring Institute launched the Household Exposure Study in 1999 to test indoor air and dust samples from 120 homes in Cape Cod, MA, for 89 endocrine disrupting compounds (EDCs), including phthalates, flame retardants, parabens, pesticides, alkylphenols, polycyclic aromatic hydrocarbons (PAHs), and polychlorinated biphenyls (PCBs) (Rudel 2003;Rudel 2008). Many of the target chemicals are considered emerging contaminants-chemicals for which exposures are not well documented and links to health are uncertain-and 30 of the compounds were reported by this study for the first time in indoor environments.
In 2004, Silent Spring Institute partnered with Communities for a Better Environment, a California environmental justice organization; Commonweal, a health and environment organization; and researchers from Brown University and the University of California, Berkeley, to expand the Household Exposure Study. The expanded study tested homes in Richmond, CA, an urban community bordering a Chevron oil refinery, transportation corridors, and other industry, and Bolinas, CA, a nonindustrial comparison community (Brody 2009; Dodson 2012; Rudel 2010). The team collected indoor and outdoor air and household dust samples from 50 homes. Samples were analyzed for over 150 compounds, including EDCs such as phthalates, PBDEs, parabens, pesticides, alkylphenols, PAHs, PCBs, and other estrogenic phenols, as well as metals and particulate matter (PM2.5), which are associated with industry and transportation. We interviewed study participants about their experiences learning their results (Adams 2011; Altman 2008). costs into the research budget when possible. If a large sample size is important, or even mandated, computerized approaches to report-back may be useful. For that reason, our team is developing and testing such approaches to support effective reportback in larger studies, such as government biomonitoring programs where individual contact with each participant may be too costly or not logistically feasible.

ROLES AND RESPONSIBILITIES
In CBPR projects, many players have important roles to play. Involving community leaders and trusted liaisons can ensure that report-back methods and messages are tailored appropriately for the study community. In addition, it is critical for the study's scientific leaders to remain responsible for interpreting data and reviewing messages to ensure their accuracy. Researchers also must make sure that everyone, including community members who are involved in reporting individual results, is comfortable with confidentiality practices and trained in human subjects protections. Some teams may involve healthcare providers in interpreting and reporting results, particularly when the provider is known and trusted by the community. Because environmental health may be outside their area of expertise, they will need to be thoroughly briefed about the scientific context, aims, methods, and results of the study as well as the interpretation of individual results for specific chemicals. In particular, they may benefit from training in messages about precautions when health effects, sources, and exposure reduction strategies for chemicals are uncertain.

INFORMED CONSENT
For research teams that have decided up front to report individual results, communication can begin with informed consent. The principle of autonomy directs researchers to provide individuals with the opportunity to decide freely if they wish to become study participants. Extending that principle to communicating results, it follows that study participants have a right to decide whether they want to know -or not knowtheir individual study results. We have found that getting informed consent for study participation and report-back at the same time is effective and convenient.
The Household Exposure Study told potential participants about the option to receive individual results in the informed consent form. Here is an excerpt: HOW WILL THE FINDINGS BE REPORTED? You will have an opportunity to learn the results for your home if you wish. In addition, a summary of the findings for all the homes together will be reported to Richmond residents in public meetings and news media. The overall research results will also be published in scientific journals. Your name and other identifying information will never be used in any reports or publications.
To help participants decide, the informed consent can clarify what information the study will and will not be able to provide. For example, in fact sheets distributed to potential participants, we communicated that the study was likely to detect pollutants in the home, but that it was not designed to find relationships between those pollutants and health effects: We are not able to draw conclusions about the health effects of exposure to the chemicals. Further studies would be needed to determine any links between exposures and health consequences.
Researchers can also articulate that reporting individual results -even when health effects are uncertain -can provide participants with opportunities to take action to reduce exposures.
The informed consent process is a good opportunity to find out whether study participants want to receive their own results. This is also a good time to set expectations about what participants will and will not be able to learn from the study.

LEGAL ISSUES
In some studies, individual results may have legal implications. For example, if an individual learns that contamination of a property could harm others, that information might need to be disclosed to those who use the property or when the property is sold. Although this circumstance would not be expected to occur in most studies, participants need to be informed during the consent process if this risk is reasonably anticipated.
In addition to the usual research practices that protect individual information, researchers can apply for a Certificate of Confidentiality, which protects the researchers themselves from forced disclosure of identifying information in federal, state, and local civil, criminal, administrative, legislative, or other proceedings (National Institutes of Health 2009). These Certificates are relatively new, so their legal limitations are not yet well understood. This Certificate does not prevent participants from voluntarily releasing information about their involvement in the research.

COMMUNICATING RESULTS FOR CHILDREN
Studies involving vulnerable populations -including participants with limited capacity for free consent or limited capacity to understand their results -require special protections. For example, the research team will need to decide if children are mature enough to receive study results or if results should be reported to parents or legal guardians, or some combination. If results are reported to children, tailored communications should be developed.

NAVIGATING THE IRB PROCESS
Once the communications strategy is developed, it must be approved by the study's Institutional Review Board (IRB)-a committee charged with overseeing human subjects research to ensure that the rights and confidentiality of individual research participants are protected (Penslar 1993). Because IRBs may not be familiar with CBPR, they have sometimes been reluctant to oversee community partners and to approve reporting individual results when health effects are uncertain. This can lead to substantial delays, diversion of study resources, and damage to community-researcher relationships. We recommend educating the IRB well in advance about CBPR and working to ensure that the IRB includes at least one member familiar with CBPR.
Brown University's IRB was initially hesitant to oversee researchers from the community partner organizations in our collaborative. In response, our team extensively discussed CBPR issues with the Brown IRB and demonstrated that the community partners were experienced in scientific research and trained in human subjects protection. We showed the IRB that CBPR processes were growing in importance and in federal funding. These efforts resulted in a novel agreement to cover the work of all partners in our collaborative (Brown 2010).
Similarly, in the CHAMACOS Study, a pesticide biomonitoring study with pregnant women and children in an agricultural community in California, the IRB initially objected to dissemination of individual results (Bradman 2007). The researchers organized meetings with various study stakeholders-researchers, community members, doctors, advocates, and industry representatives-during which advocates and industry demonstrated support for returning individual results. One community member expressed study participants' right-to-know, saying, "I think you will get a very positive response from the women. They are very interested in their children's health and how to improve it. You need to give them access to their results." The team was able to use this information in their efforts to educate the IRB, which ultimately led the IRB to reverse its initial decision. Study participants may be able to reduce exposures by switching products.
Still, some researchers have found that IRBs only allow "passive" report-back in which the responsibility is on the participants to call and request their data. And some IRBs have forbidden advocacy groups from even conducting biomonitoring research in which report-back would be a component of responsive community engagement. We hope these barriers will fall as IRBs become more familiar with effective practices.
Based on our experience and research, we suggest the following strategies for research partnerships: • Get to know the IRB. Becoming familiar with IRB members before the review process can help researchers assess their familiarity with CBPR and the extent of education they may need.
• Take time to educate the IRB. This may involve such activities as preparing memos on the history, principles, and practices of CBPR; maintaining regular contact with IRB staff through emails and in-person dialogue; demonstrating precedent by pointing to other successful projects; and inviting IRB staff to CBPR workshops or other educational events.
• Make sure academic IRBs know community partners. Academic researchers can connect community partners with IRB staff to demonstrate the community's involvement in the research process and how this involvement is key to the project's success. Research partners can include a description of "community consent" in their IRB application.

MORE THAN "ONE SIZE FITS ALL"
Research teams that have decided to report individual results will then need to determine how, including the content and process of report-back. Some of the questions facing researcher teams about report-back include: • What information do we report? All or only some of the results?
• How do we design the materials? Graphs, text, pictures?
• How do we distribute the results? Mail, in person, drop-off, or at a community meeting or clinic visit?
• When do we report results? Before or after disseminating results in peer-reviewed journals and conference presentations?
• What if there is a problem with report-back? What if a participant is upset?
The information in this chapter is intended to help guide teams through the decisions about how to report results. First steps include engaging community representatives in the process to help ensure that report-back is conducted in a way that is understandable, meaningful, and culturally appropriate. We have also found it helpful to consider principles and experiences in risk communication, such as strategies for building trust, respecting cultural context, and considering how people process information.

CONSIDERING PRINCIPLES OF RISK COMMUNICATION
Research on risk perception has shown that when people make judgments about risk under uncertainty they rely on various heuristics to simplify their decision-making process (National Academy of Sciences 2006; US Environmental Protection Agency 1988). Heuristics are simple, often unconscious, "rule of thumb" decision-making strategies that are practical shortcuts for complex situations and incomplete information but sometimes result in misjudgment. For example, people tend to underestimate the risk of a common hazard, such as driving an automobile, while overestimating the risk of a rare, memorable one, such as a shark attack. At the same time, people tend to judge a hazard based on how easily they can recall or imagine an event, so they may overestimate the risk of a hurricane if one has been in the news recently. Reliance on such rules of thumb has the potential to lead participants to under-or overestimate risks associated with study findings. Although it is difficult to anticipate how participants will respond to receiving their own results, it is helpful for teams to keep these principles in mind as they develop a report-back plan. Consulting with community representatives throughout the process will give researchers a heads-up about information needs and potential misunderstandings.

DECIDING WHAT TO REPORT
When deciding what information to include in report-back materials, research teams can begin by working with community members to determine what study participants want to know. In our Household Exposure Study, we sought input from study participants, community leaders, advisory council members, and other researchers about what to report. We summarized participants' questions about their results and identified what study data would best answer those questions (Brody 2007) ( Table 2). Over the years, we have found these questions to be an excellent reference for preparing report-back materials.
Quandt et al. (2004) also conducted informal interviews with study participants and community members to assess participants' communication needs. During these interviews, participants reported that they wanted more rather than less information, even if the health effects were uncertain: In terms of ambiguity, [the participants] thought it was important that scientists present "la verdad" (the truth). If this meant telling women that it was not possible to know the level of danger represented by the findings, they would prefer to know that rather than to have the scientists give a simpler, but incomplete answer. List of types of products or processes that commonly contain or emit detected chemicals such as combustion and auto exhaust or specific types of consumer products

What can/should I do?
Individual and community exposure-reduction strategies, precautionary strategies, research needs Similarly, a focus group of parents in the CYGNET Study of puberty in girls found that they wanted to receive comprehensive information about all chemicals, including chemical sources and potential health effects (Brown-Williams 2009b). The Child Health and Development Studies formed an 18-member Participant Advisory Council that meets regularly to guide this cohort study, and this group has enthusiastically discussed report-back options, considering models from earlier studies and their own values and priorities (Judd 2012).

DESIGNING REPORT-BACK MATERIALS
Designing individual reports for personal exposure and biomonitoring studies presents significant challenges when results involve multiple media (e.g., air, dust, blood, urine), a large number of unfamiliar chemicals, or chemicals for which there are limited or no health-based guidelines or comparisons from other studies. Furthermore, participants may have varying levels of literacy and numeracy; and researchers may lack experience reporting results to non-scientific audiences.
When determining which materials and formats to use, teams need to consider the nature of the study data, key messages, the preferences of the study community, and what resources are available. Report-back materials may include graphs, text, pictures, video, DVDs and other media or a combination. Some studies may present opportunities to experiment with new media, such as interactive web-based tools; however, these formats may raise additional challenges to protecting confidentiality. Engaging community members or trusted representatives can help teams design materials that are appropriate. Teams can assess participant preferences through focus groups, community meetings, conversations, surveys, or other methods.

Combining graphs and text
Based on our experience, report-back that includes a mixture of information-rich graphs and brief verbal summaries allows for individual differences in the ability and desire to understand report-back information. Some participants prefer text summaries while others are more comfortable with graphs and images. Keep in mind that well-designed graphs rely on people's natural ability to judge above/below and larger/ smaller relationships and can depend less on literacy and numeracy than text or tables.
We used a combination of materials in our Household Exposure Study. Results were presented to participants in packets (Appendix A) that included: • Cover letter that introduces report-back and reviews the goals of the study • A half-page narrative summary of key results and exposure reduction implications for the participant's home • One-page guide to reading the graphs ( Figure 1A)

Graphs and tables
Graphs and tables are efficient ways to present quantitative data and the comparisons that give the results meaning.
Tables are useful for listing precise results or comparing one result to a health guideline (Few 2004). For participants used to receiving medical results, table formats may be familiar. They are also compact for reporting large numbers of findings.
Graphs are preferred for communicating patterns in data (Few 2004). As a result, graphs are useful for presenting results for chemicals for which there are limited or no health guidelines and interpretation is based on distributions and comparisons of results, for example, across media, locations, and chemicals. In addition, graphs avoid some of the limitations of tables and text, which are more dependent on literacy and numeracy (Few 2004). Graphs communicate basic concepts, such as larger/smaller, above/below, and many/few that correspond to key study messages. The specific type of graph used will depend on the information being communicated as well as participants' preferences. We have included a variety of graphs as examples below.
Our team has experimented with several types and versions of graphs, informed by the type of data in the Household Exposure Study and feedback from community members and study participants. Selecting and developing appropriate graphs has been an iterative process and continues to be a work in progress.
Graphs should be designed to be self-explanatory. In our experience, though, participants who think of themselves as unskilled with numbers are reassured when we present a "how to read the graph" guide before presenting individual results graphs (Figure 1A and 1B). While the first reactions of some professional risk communicators and environmental literacy practitioners consider our graphs to be "too difficult," we have observed community members in many different settings reading them successfully. We think this is because they are visual communications -"pictures" -rather than relying fundamentally on literacy or numeracy. Since we began using these methods, participants and community members affiliated with other studies have also found that graphs worked well to communicate results. Sometimes it takes a few minutes for study participants to begin reading the graphs, because they don't have confidence in their science competency. We are developing strategies to help break down confidence barriers and build environmental health knowledge.
When studies have very large numbers of results to report, graphs may be used to convey the most meaningful or important results, accompanied by tables to make reports comprehensive. We have sometimes graphed "indicator" chemicals to represent a type of exposure.

Examples of individual results
We used simple strip plots in the Household Exposure Study to communicate how much of each chemical was found in a given sample compared to other study participants and a health-based guideline when available (Figure 2). Variations of this basic approach have been used successfully in several studies. Additional modifications that address the difficulty people have with logarithmic scales would be a further advance.
In another example, the CYGNET Study used strip plots to report levels of environmental chemicals in participants' blood and urine (Figure 3). Each participant's value is compared with other study participants and a reference value.
Bar charts are also useful for displaying individual results relative to other participants and guidelines, and across different media or communities. For example, an advocacy biomonitoring study of consumer product chemicals in volunteers in seven states used bar charts to report on levels of bisphenol A (BPA) in participants' blood and urine (Figure 4).
Biomonitoring allows study participants to learn that chemicals in the environment and everyday products end up in their blood, urine, finger nails, breast milk, and other tissues.

WWW.SILENTSPRING.ORG
For studies involving data collected over time, line graphs may be appropriate to communicate rates and magnitudes of change in levels of target chemicals.
Shaded grids may be useful for communicating values such as detect/no detect or safe/unsafe. For example, Quandt et al (2004) used a grid to display what and how many pesticides were detected in households in their study ( Figure 5). These graphs show pesticides in columns and households in rows, with shaded cells indicating if a chemical was found in a participant's home.
Shading can also be used to convey concepts like "high, medium, low" or "safe, unsafe." We used the traffic-light colors red, yellow, and green to indicate to Cape Cod residents whether nitrate measured in their drinking water was similar to natural background levels (green), approaching a level of concern (yellow), or above the regional health guideline (red) (Figure 6).

Study-wide results
Graphs of study-wide results help participants understand the overall findings and put their own results in context. These graphs communicate important environmental and health messages and help participants understand how their own data contributed to knowledge.
To show community-level comparisons between Richmond, an urban environmental justice community, and Bolinas, a rural comparison, in the Household Exposure Study, we have used box plots. Box plots are useful for interpreting the distribution of a dataset. They quickly communicate "typical" results represented by the "box" and show the distribution of outliers, represented by the confidence interval lines and dots, sometimes called "whiskers." (Figure 7) However, based on feedback we received from participants and community members who found the box plots difficult to understand, we are currently experimenting with using strip plots for comparisons between communities (Figure 8). In this example, individual results are "jiggered" horizontally, so that they don't lie on top of each other. This can be accomplished in standard graphing software.
A cumulative bar chart was helpful for comparing the number of chemicals at higher levels across the two communities (Figure 9).
In another example, the Growing Up Female Study in Ohio used strip plots to show dramatic differences in blood levels of PFOA in two communities. The graph shows individual results relative to other participants and the national average (Figure 10).
Another graph showed averages for each community relative to workers with high exposures, the national average, and girls from the San Francisco Bay Area ( Figure  11).

AREA (GROWING UP FEMALE STUDY) (HERNICK 2007).
Put results in context with comparisons Many of the example graphs include comparisons to other studies or to benchmarks. Incorporating risk comparisons like these in report-back materials can help participants contextualize unfamiliar information and inform decision-making. By benchmarks we mean guidelines such as those established by federal agencies like the U.S. EPA. Levels approaching or exceeding benchmarks may signal potential health concerns. While benchmarks may be useful when available, official health guidelines have not been established for many emerging contaminants. In addition, some guidelines that exist are outdated, so they do not reflect current science. They may even be confusing, because they don't take into consideration the study's research hypothesis. In these situations, it can be difficult to decide whether to show benchmark levels.
For personal exposure studies involving chemicals with limited or no health-based guidelines to use as benchmarks, individual results can be compared with the study population, or a reference group, such as the National Health and Nutrition Examination Survey (NHANES), which reports on chemical exposures in a representative sample of the US population. While useful, these comparisons have the potential to lead participants to over-or under-estimate risks or to misinterpret reference group levels as safety benchmarks (Brody 2007). For example, a participant who discovers that the level in her home falls below the study average may interpret her result as "safe," whereas another participant may be concerned to find his value falls at the upper end of the study distribution, even if the entire distribution falls below a benchmark. To clarify the interpretation for participants, research teams should define the reference levels used to ensure that they are not confused with regulatory benchmarks.
Highlight key messages with text While graphs are useful for visualizing data, verbal summaries can draw attention to key messages from the graphs, help participants contextualize their results, and share with participants the researchers' expert judgment. This is particularly important in studies that are testing for numerous analytes and in different media (e.g. dust and air, or urine and blood), because the short summaries draw attention to what's most important. Reports to participants in our studies included a half-page to one-page narrative summary of results and exposure reduction strategies for the participant's home (Appendix A).
For example, one participant's summary had the following information about flame retardants: Your house contained PBDE flame retardants. The PBDEs in your house dust were generally higher than most others in the study (See page 9, PBDE). PBDE flame retardants are in foam furniture and cushions, and synthetic carpets. These chemicals were banned in Europe because of effects on thyroid hormones.
Another participant's summary placed the participant's result in the context of the other participants and a benchmark: You also had the highest level of lead (Pb) in your outdoor air, but this level was much lower than the EPA lead standard (page 2, Pb).
The verbal summaries included practical steps for reducing exposures: We found two insecticide ("bug killer") ingredients in your indoor air (page 2) and dust (page 8). You can reduce your exposure by controlling indoor pests with bait traps and other less toxic methods. We found it useful to have team members work together to develop prototypes of the short summaries and to have each team member write up some of the short summaries, which we then compared, in order to check our consistency concerning both style of presentation and choice of what content to emphasize.
We included fact sheets about the study (Appendix A) and the chemical classes (Appendix A) in report-back packets to provide further contextual information. The study fact sheet communicates information about the goals and methods of the study, who is conducting the study, how the results are reported, and how participants can contact the study team if they have additional questions. The chemicals fact sheet explains potential sources and health effects, and names an example from each chemical class in the study. These early examples of our work have been helpful to teams who have developed their own report-back protocols. It is important to keep in mind that materials development is an iterative process as communication methods continue to improve.

Address the need for information about actions to reduce exposure
The report-back process is an opportunity to provide information about strategies for reducing exposure to target chemicals. Like health information, exposure reduction information should be based on the strength of evidence, and researchers need to be clear about when more research is needed before recommendations can be made (Brody 2007).
In two pesticide exposure studies, participants reported that information about exposure reduction was the most important part of the report-back process (Morello-Frosch 2009). Participants in our studies also expressed similar priorities: And that's what I would want from this study is give me something I can do about it. Don't just give me information that tells me I have problems.…Because that's frustrating, you know? But I'm proactive enough that I'll say, "Ok, I have this information now it's up to me to do something. It's not enough for you to do it for me but just to give me some options of what I can do to change it." That, I would think, with this study would be the most important thing….

Individual actions
To inform exposure reduction, we included information about possible sources of target chemicals and exposure reduction strategies in the verbal summaries (Appendix A), a detailed chemical sources table (Appendix A), and fact sheets. The chemical sources table was designed to help participants identify the products and practices that could produce the chemicals detected in their home. During report-back consultations and at annual community meetings, team members provided handouts about exposure reduction strategies based on the participants' study results and community context. For example, in response to detecting pesticides, we provided handouts about Integrated Pest Management (IPM). Other handouts included information on wood burning stoves and flame retardants. In response to community members' interest in exposure reduction related to cleaning products and practices, we developed a "Greening your cleaning" fact sheet (Appendix C).

Community-level and policy action
While providing information about individual exposure reduction strategies is useful, it is also important to offer recommendations for community and policy level actions. We told participants in our study how a particular chemical is regulated in the US and in Europe and provided information about our community partners' advocacy campaigns (Appendix D). During community meetings, participants brainstormed creative ways to apply study findings to grassroots organizing, including using individual study Studies involving children or samples taken during pregnancy raise special issues for reporting results. The CYG-NET Study, Chemicals in Our Bodies, and Growing Up Female offers successful models. results in testimony at city council hearings about the proposed expansion of a nearby oil refinery. This demonstrates that report-back can be valuable even for those residents who are not participants in the study itself, since their community as a whole is affected. This value-added involves both the education about contaminants and the collective motivation to take action.

Getting comfortable with uncertainty
Although providing information about action can help participants reduce their individual exposures and leverage results to support advocacy efforts, the health effects of target chemicals may be uncertain; and interventions can be costly, inconvenient, and difficult to implement. Furthermore, there is a dearth of evidence-based information about the efficacy of many exposure reduction strategies. As a result, we caution researchers to acknowledge this uncertainty and not allow the wish to "fix" things and reduce worry to lead to unsubstantiated reassurance or recommendations. We developed a conceptual graph (Figure 12) (Brody 2007) to help shape recommendations for action based on how much is known about a chemical's health effects and exposure reduction strategies. Increasing certainty about health effects and exposure reduction leads to clear recommendations for individual and community level action, whereas decreasing certainty leads to recommendations for further research and precautionary exposure reduction.

Consider varying levels of literacy and numeracy
Personal exposure studies may involve participants with varying levels of literacy, numeracy, and environmental health science knowledge. Populations with lower levels of scientific literacy are as interested in receiving their individual data as are more educated groups and are able to grapple with uncertainty (Adams 2011; Brown-Williams 2009a; Morello-Frosch 2009; Quandt 2004). To successfully communicate personal exposure results to participants with lower levels of literacy and numeracy, teams can incorporate basic health communication practices, work with community members to assess participants' needs, and pilot test materials to ensure they are understandable, engaging, and relevant.
Our approach is to rely as much as possible on people's basic capacities and common sense, de-emphasizing skills and information learned in school. Nearly everyone learns to interpret spoken language and visual relationships in early childhood. We have found that using graphs and creating opportunities for conversation, such as community meetings or one-on-one interviews, is particularly helpful.

Consider community context
Health educators emphasize the need to consider study participants' sociodemographic characteristics, including language, education level, age, ethnicity, and gender. In addition, it is important to take into account the study community's unique social, historical, and environmental setting. Our research suggests that participants' prior experience with illness and environmental pollution may shape their interpretation of and response to personal exposure study results (Adams 2011; Altman 2008). For example, participants in our Household Exposure Study initially associated pollution with local sources, including a military reservation, a refinery, and other industry, and with well-known contamination events outside the community such as Love Canal. This focus on outdoor pollution sources led many participants to overlook sources from everyday consumer products and activities. In another example of how history affects report-back, in Richmond, CA -a community bordering an oil refinery, other industry, and transportation corridors -the active organizing and policy campaigns Study participants are often surprised to learn that drinking water contains both regulated and unregulated contaminants.
of study partner Communities for a Better Environment gave study participants a better baseline understanding of how community-level action can address exposures. Our findings underscore that there is no one-size-fits-all model for report-back; rather, decisions about reporting results will depend on the particular study and community. Considering community context when deciding how to report results will help ensure report-back is understandable and meaningful.

Pilot test materials
Developing report-back materials is an iterative process. In order to experiment with various designs and modifications to find the right fit, teams can collect informal feedback from community representatives or conduct more formal communications studies or pilot testing to evaluate whether report-back materials are responsive, understandable, appealing, and appropriate.

DISTRIBUTING RESULTS
Options for disseminating results include mail, telephone, drop-off, face-to-face, internet, or a combination of approaches. Consulting with community members will help teams determine a suitable process. In our experience combining communication materials with in-person home visits works well; however, this is not always feasible.
Our Northern California Household Exposure Study used a combination of mail, drop-off, telephone, and face-to-face communication for reporting results.

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WHEN POLLUTION IS PERSONAL member first called participants who had requested their results during informed consent to let them know they would receive a packet of their results in the mail and to invite them to schedule a home visit to review the results. Results packets were then mailed or hand delivered. During home visits, team members reviewed the results packets, answered questions, and provided information about exposure reduction strategies (Appendix B).
Our interviews with participants reveal that they appreciated the opportunity for the face-to-face conversations (Adams 2011). One participant commented: …just very supportive comments and good insights in terms of how my place registered in relation to the others that have been tested. And the sense, I got the sense that there were things that I could do and that helped.

COMMUNITY REPORT-BACK
Research teams that develop report-back protocols need to carefully consider the relationship between reporting results to individuals and reporting aggregate results to the study community, the broader scientific community, and the news media. Based on our experience, we suggest the following guidelines for community level report-back: • Host community meetings. This can provide opportunities to present aggregate study findings to community residents, study participants, public officials and other stakeholders; answer questions about the study; provide information about exposure reduction strategies; obtain feedback about the study and report-back process; facilitate discussion about study findings; and provide an opportunity for participants to brainstorm ways to act on study findings. If there is a community advisory board (which we generally believe to be integral), advisers should be encouraged to attend and co-host the meeting.
• Provide brief fact sheets. Include information about why and how the study was done, the results, and their meaning and implications for action at both the individual and community or national level. Remind participants what information the study can and cannot provide. Those attending community meetings can take this fact sheet to others to further disseminate findings.
• Publish study findings. Publishing study findings in scientific journals is a no-brainer for researchers, but we also consider it a CBPR responsibility in many studies. It supports translating study findings into policy. It also aids community outreach, because peer-reviewed publication signals to journalists that the work is scientifically sound, encouraging them to cover the story. We encourage researchers to publish their report-back methods and evaluations, too.
• Be proactive with media. Media coverage of study findings becomes part of the report-back experience for participants. CBPR scientists need to coordinate strategies, roles, and messages with community partners. Developing media talking points before community meetings and issuing press releases can provide teams with greater control over messaging, improving the accuracy of the reporting. Working with the news media can be a highly cost-effective strategy for reaching study participants, community members, and decision-makers. Don't forget to include Spanish-language press or others relevant to specific studies.
• Incorporate fact sheets and action links on web sites and in social media. Online communications may reach a different audience and links to community organizations or national policy action can help people take action on what they have learned.
A comment from another participant reflects that the report-back conversations built trust: I felt good someone was recording these things and that maybe there would be some results or some, you know, future improvement because of the study. And that somehow industry might not be able to get away with as much as they do get away with. There would be more awareness. So it was good, I felt good about that. That we weren't just being ignored.
Such resource intensive face-to-face meetings may not be possible for larger scale studies. In these cases, mailed materials combined with a clear way to contact a research team member with follow-up questions or an online tutorial or video could serve a similar function. Regardless of which strategy a team chooses, we expect a researcher would still need to be accessible by phone to respond to questions. Based on our experience, the research team can expect a small number of participant queries. In addition, researchers may want to phone participants with unusually high measurements. We used this strategy for homes in our Cape Cod Household Exposure Study where we found exceptionally high levels of contaminants in about a dozen homes (Rudel 2008). This additional contact enabled us to discover the source of high PCBs.
Active versus passive reporting While our study used an active form of report-back in which participants were asked directly if they wished to receive individual results, some teams have used a passive, or "opt-in," form, where participants must contact the study team to request their results. Although both methods can provide participants with the option to not receive their results, passive reporting makes it harder for participants who do want them. Experience shows that participants who wish to receive results don't always contact the research team to get them. One researcher we interviewed noted that a third of participants who did not initially call for results later expressed interest in getting their results during a follow-up survey a week later (Morello-Frosch 2009). A recent assessment by Wu et al. (2009) found that the passive reporting techniques used in a breast milk biomonitoring study created a barrier to accessing results. In that study, only 30% of participants contacted researchers for their results after receiving a letter letting them know there results were available. In contrast, nearly all participants elected to receive their results in our active-report-back study. We believe asking participants directly whether they want their results is more respectful than placing the burden on them to ask.

Timing
Reporting individual results should be part of a strategy for reporting aggregate results to the study community, the broader scientific community, and the news media (See Box on community report-back). The sequence of these events depends on weighing a number of factors: participant and community wishes, time required for data analysis, scientific journal publication practices, and media coverage of results presented at scientific conferences. Study teams have a responsibility to return results promptly; however, reporting results too soon could mean the interpretation doesn't benefit from the peer review process. Also, peer-reviewed publication is a signal of credibility to the news media, which affects the coverage and impact of the results.
However teams decide to proceed, they should communicate with participants up front about expected timing and update them if the schedule changes.
Community first report-back The community advisory council for a study of PFOA in residents of Little Hocking, Ohio, developed a "community first" communication model that carefully timed sequential communications (Emmett 2009). After peer-review but before publication, results were reported to participants, local medical providers, and relevant authorities, followed by the news media and the local community. Researchers may find that some communities, especially tribal ones with their own IRBs and similar bodies, have express criteria for "community-first" report-back.

Develop a response plan
Learning about contamination in one's own home or body can be worrisome, and research teams should be prepared to respond to concerns. Some researchers have worried that reporting individual results when the health effects of target chemicals are uncertain could particularly cause undue distress. The experiences in our Household Exposure Study and other studies described in this handbook have been reassuring. In the Household Exposure Study, most participants had a moderate response to receiving their results. Some were initially surprised or puzzled by results but not unduly worried. We found that making team members available to answer questions and provide recommendations for action helped participants process the information and mitigate distress.
Teams can be proactive by developing a plan and delineating responsibilities for how they will respond to participants' questions and concerns, for example about the health implications of the findings or opportunities for exposure reduction. Resources should include both a senior researcher, who knows the underlying science, and someone who is connected with and skilled at talking with the study participants' community, whether community is geographically based or defined by shared illness or cultural experiences.
Our team and colleagues who have reported individual exposure results have found this to be a valuable experience for both researchers and participants. Research about report-back documents that these methods can be effective. We are eager to hear about your experiences, too. WWW.SILENTSPRING.ORG ). This is a new field, though, so collecting additional information about participants' experiences, including how they perceive and act on their results, can help improve ethical and effective approaches. Methods for evaluating report-back include interviews with participants after they receive results, surveys conducted at community meetings, and focus groups.

PLANNING AHEAD
Developing an evaluation plan early in the report-back process can help teams allocate adequate time and resources, avoid IRB roadblocks, and facilitate interviews with participants soon after they receive results. Keep in mind that evaluation materials used with participants need to be approved by the study's IRB. It may be helpful to partner with a social scientist who has experience with qualitative techniques to develop and implement the report-back evaluation.

INTERVIEWING PARTICIPANTS ABOUT THEIR EXPERIENCES
Interviews with participants can provide rich information about their experiences with receiving their own results and the effectiveness of report-back practices. The planning steps include developing an interview schedule, getting informed consent, selecting interviewers and interviewees, conducting interviews, and interpreting participant responses.

Developing an interview protocol
Interviews with participants can provide rich information about their experiences with receiving their own results and the effectiveness of report-back practices. The planning steps include developing an interview schedule, getting informed consent, selecting interviewers and interviewees, conducting interviews, and interpreting participant responses.

WANT."
In our Household Exposure Study, we used a semi-structured interview organized around topics such as participation in sample collection, interpreting and understanding results, and general implications of the study (Appendix E). For example, our interviews begin with questions that engage participants and are easy to answer, and then the section about interpreting results asks the following question and series of follow-up questions:

Do you recall what the study found in your home? [Long pause, wait for answer]
a. Do you remember any specific chemicals that were found in your home? b. Would you say that the levels of any chemicals found in your home were "high"? i. This example illustrates some additional features of interview schedules including the use of open-ended questions, which encourage descriptive answers, and probes, which allow interviewers to follow-up for clarification or additional information. As with report-back materials, when developing interview schedules, teams should consider socio-demographic and community context. Interview protocols may need to be translated and conducted in multiple languages. Include terminology that is consistent with other study materials such as the report-back packets and study fact sheets. We go through many iterations in order to best cover a lot of material without too many questions, and with a combination of the most precise wording and the most openness to elicit detailed responses.

Getting informed consent, again
Teams that decide to interview participants will need to obtain informed consent for the interviews. We first discussed follow-up interviews with participants in our Household Exposure Study during informed consent for sample collection and included this text in the informed consent form (Appendix E): If you choose to receive your results from this study, we will visit you a third time after you receive the results to interview you about your experiences participating in the study and receiving your results. The third visit will last approximately one hour.
When we met with participants to report their individual study results, we asked for permission to re-contact them to ask about their experience. After we reported results, we phoned participants to schedule visits to their homes to conduct the follow-up interviews. During the follow-up visits we obtained informed consent for the interviews. For example, our informed consent form (Appendix E) includes the following text: In the Household Exposure Study, participants were surprised to learn that pesticides used on weeds outdoors were tracked inside. Now, if you agree, we would like to interview you about your response to how we reported to you what chemicals we found in your home. The interview will take about an hour. The questions are designed to help us evaluate how well we did in informing study participants about what was found in their homes and also to find out what people think was important about their results. With your permission, we will tape record the interview to ensure that we get the most complete record of your responses.

Selecting interviewers
Interviews can be conducted by trained researchers or community members who are familiar with study findings and how to interpret them, but may be blinded to individual participants' results. They should be prepared to answer questions about how to read the graphs, sources of target chemicals, and exposure reduction strategies. For example, interviewers for our Household Exposure Study found it useful to bring a packet of handouts covering relevant exposure reduction strategies such as IPM.

Conducting interviews
Conducting interviews in-person can create a rich interaction that allows interviewers to pick up on non-verbal cues and build rapport. Conducting interviews over the phone is another option. In an evaluation of a breast milk biomonitoring study, Wu et al.(2009) conducted brief telephone interviews to evaluate the report-back process and assess how participating in the study and receiving results affected participants' attitudes towards breastfeeding.
Teams may wish to interview only a subset of participants, particularly in studies with larger study populations. Based on our experience in the Household Exposure Study and on experience in mental models studies (Morgan 2002), approximately 20 -25 interviews is enough to provide saturation; that is, the point at which responses largely duplicate prior participants' answers. A larger number of interviews would be needed to evaluate how common certain types of responses are, especially if there were multiple racial-ethnic and income groups.
When developing and conducting interviews, it is important to keep in mind that the interviews are not meant to "test" participants, but rather to elicit participants' experiences with and views on report-back. Focusing on participants' experiences rather than on what details they can recall will generate more helpful responses. We avoid "test-like" questions that make the interview seem like an evaluation of the participant rather than an inquiry about the report-back process.

Case Study: Household Exposure Study
In our Household Exposure Study, we evaluated our report-back process by conducting hour-long in-person interviews with 57 study participants (Adams 2011; Altman 2008). Interviews were designed to assess: • How participants interpreted the materials • What information helps participants understand and contextualize results

• Participants' emotional responses to receiving results
• What practices are appropriate in particular community contexts • What actions participants considered or took in response to receiving their results Interviews revealed that participants from diverse socioeconomic and educational backgrounds were able to grapple with complex results and uncertain health implications. Participants learned about everyday exposures to environmental chemicals, demonstrating how report-back can increase environmental health literacy. We found that participants understood key messages from the study findings. Participants often expressed surprise at their results but not undue worry or stress. "It's interesting how the indoor [pollution] is higher in both of the communities… I mean they're very starkly different. Polar opposite-type of environments." Interviews revealed that reporting individual results motivated individual and collective action to reduce exposures.

Case Study: La Familia Study
In the La Familia Study, Quandt et al (2004) conducted in-person interviews to assess participants' reaction to receiving information about pesticides detected in their homes, how participants interpreted the report-back materials, and how well the study's main risk communication messages were conveyed. Interviews revealed that participants were able to comprehend the main points of the risk communication and to interpret the figures presented. The findings indicate that even participants with low literacy were able to understand complex scientific concepts. Participants' reactions to results varied, including relief, surprise, concern, and complacency.

Case Study: Greater Boston PBDE Breastmilk Biomonitoring Study
In the Greater Boston PBDE Breastmilk Biomonitoring Study, Wu et al (2009) conducted brief telephone interviews to assess how participating in the biomonitoring study and receiving results affected participants' attitudes towards breastfeeding and to evaluate the report-back process. Findings suggest that receiving individual results and other study materials did not negatively impact breastfeeding behavior, and that the context and manner in which the results were reported mitigated any potentially negative impacts. Participants' responses indicate that the study provided an opportunity for learning about environmental health and motivated some participants to reduce exposures or engage in other preventive behaviors.

Case Study: The Growing Up Female Study
Parents of participants in the Growing up Female Study, an epidemiological study of young girls in Ohio, reported a positive experience receiving individual test results of blood levels of PFOA (Hernick 2011). One participant commented, "Let me get this straight: You have found something, you do not know the cause or solution? Thank you for doing the right thing morally and ethically for sharing this information with us" (Hernick 2007). Other benefits of reporting individual results noted by the study team include providing parents with a better understanding of the relevance of the study, an opportunity to dialogue with study families, and better study retention.

EVALUATING COMMUNITY MEETINGS WITH SURVEYS
In the Household Exposure Study, aggregate results were reported at community meetings held in the study communities. To evaluate this part of the report-back process, we distributed anonymous five-question surveys at the community meetings that asked attendees why they attended, what they hoped to learn, and what followup questions they may have. We learned that people felt they learned a lot from the presentations, were grateful for the information we presented, and felt they could use the information to improve their community (Appendix F).
Chemicals from consumer products linger in household air and dust, exposing everyone in the home. Feedback from community members can help researchers design charts that are easier to understand. Encouraging and teaching participants to read graphs is a valuable part of report-back.
Active report-back of personal exposure data to participants is an exciting area that combines good environmental health science, democratic ethics, and community empowerment. This approach offers the potential for high quality, innovative science that at the same time benefits individuals and communities who participate. As a fairly recent approach, report-back has begun to have important impacts, especially regarding emerging contaminants about which little has been previously known. As with any new approach, practitioners, participants, and IRBs often lack guidance on how to do this work. This handbook provides that guidance, as well as offering scientific support for this approach.
Researchers, government agencies, and community groups engaged in biomonitoring -and other personal exposure studies, such as household sampling, as well -can benefit from extensive communication with each other about their experiences and their hopes for expanding and improving such work in the future. We seek communication from others engaged in report-back, so that we can update this handbook and serve as a resource for others involved in similar work.
We welcome your input. Please send comments about this handbook and examples of your own approaches to us at info@silentspring.org. We are doing this study because most people spend much of their time at home, so chemicals that people are exposed to at home can be important for health. We are studying chemicals that come from activities inside the home and pollutants that may come from outside. For some chemicals, your results can be compared to a government health guideline. For other chemicals, scientists don't know yet how they affect health, and measuring household levels is the first step.
Some people in the study may want to make changes to reduce the levels of some of the chemicals we found. To help people think about ways to reduce exposure, we have included information about the products, materials, or activities that may be sources of the chemicals in your home or local environment. This information is in your summary and in a detailed table listing each chemical along with a key to the abbreviations used in the graphs.
We know that some people are more comfortable than others reading graphs and tables like the ones included, and we would be glad to talk with you to help you understand your results or answer any questions. Please call Communities for a Better Environment Project Coordinator, Carla Perez, at 510-302-0430 ext. 11 if you have any questions about any parts of the study.
In addition, we will be inviting you to a series of community information sessions over the next two years where we will discuss what we learned from this sampling program. We deeply appreciate your active participation in this project.

Summary of Your Results
We tested for 185 chemicals in this study. Overall, we detected many chemicals in every home. Your results are shown in the enclosed graphs.
For your home, we detected: • 27 chemicals in the outdoor air near your home, • 33 in your indoor air, • 11 in your dust sample.

Brominated Flame Retardents
Your house contained PBDE flame retardants. The PBDEs in your house dust were generally higher than most others in the study (see page 9, PBDE). PBDE flame retardants are in foam furniture and cushions, and synthetic carpets. These chemicals were banned in Europe because of effects on thyroid hormones.

Pesticides
We found two insecticide ("bug killer") ingredients in your indoor air (page 2) and dust (page 8).
You can reduce your exposure by controlling indoor pests with bait traps and other less toxic methods.

Phthalates -Vinyl, Other Plastics, and Cosmetics
Among the 50 homes in our study, you had one of the highest levels of DEHA in air (page 4) and DEP in dust (page 9). You had generally higher levels of phthalates in your outdoor air. We can't tell from this test exactly what the sources of these chemicals are, but the indoor sources could be from cosmetics and products like cologne, a shower curtain, plastic toys, a raincoat, or food packaging. Phthalates were banned from children's toys and cosmetics in Europe, because of concerns about effects on children's development. Phthalates are widely used in the US, and we found phthalates in every house we tested.

Polycyclic Aromatic Hydrocarbons (PAHs)
Some PAHs in your indoor air were higher than others in the study (page 5). PAHs in your home may come from outdoor air sources. Common outdoor sources of PAHs are cars, buses, trucks, and industrial emissions. Common indoor sources are home heating, cooking, and smoking.

Other
A group of chemicals called Alkylphenols are often found in soaps, detergents, and some pesticides. In your indoor air, you had a higher level than most of 1) a chemical found in disinfectants or mothballs (See page 7, 24DCPh), and 2) a chemical found in soaps and detergents (See page 7, NP).
The study team is continuing research to learn how to reduce exposures to pollutants in homes. X shows the current EPA health guideline. If your bar is above the X, your results are higher than the guideline.
Your results are marked by orange bars.
If there is no orange bar, then the chemical was not detected in your home.
Each represents one other home's indoor air result in the study, and each O represents one other home's outdoor air result.
The column of circles shows the range of concentrations measured.
If your bar is near the top, your result was higher than most; if your bar is near the bottom, your result was lower than most.
You can find more information about each chemical by matching the abbreviation on the graph with the full name on the "Sources" chart.     • En general, los niveles de contaminación son más altos adentro de las casas que afuera.
• Las partículas pueden causar problemas respiratorios, problemas del corazón, y agravar el asma. -- Insecticide (bug killer) used for over-the-counter ant and roach sprays, garden and lawn sprays, vegetable crops, tobacco, corn, citrus. Sales for residential use were banned by EPA in 2004, but limited use continues.
In 1974 EPA restricted its use to termite control, non-food seed and plant treatment, and nonagricultural applications. Not registered for current use in the United States.

Sources of chemicals and amount detected in the CA Household Exposure Study
In how many homes did we find it?

Chemical
Abbreviation What is the source? How is it used?

Sources of chemicals and amount detected in the CA Household Exposure Study
In how many homes did we find it?

Number of Detects (%)
heptachlor Hept Former insecticide (bug killer) used for agricultural crops, lawn and garden, termite control, seed treatment; repellant spray used for flies, fleas, and mosquitoes. Most registered uses were cancelled in 1978.

(59%)
pentachlorophenol PCPh Insecticide (bug killer); herbicide (weed killer); molluscicide; fungicide; algacide; germicide (trays in mushroom houses); common wood preservative. No longer available for over-thecounter sale in the United States but currently registered for use in United States pending pre-Registration Eligibility Decision by the EPA. bisphenol A BPA Used in production of polyester, epoxy, phenoxy, and polysulfone resins, polycarbonate, and hydroquinone; fungicide; ingredient in flame-retardants and rubber chemicals.

4-Nitrophenol 4NPh
Industrial manufacturing and processing (drugs, fungicides, dyes), gasoline and diesel exhaust, breakdown product of the insecticide parathion. Most people spend most of their time at home, so chemicals that people are exposed to at home can be important for health. We are studying chemicals that come from activities inside the home as well as pollutants that may come from outside. The goal is to learn about patterns of exposure inside homes. We are also trying to learn how to reduce household exposures.

WHO IS DOING THE STUDY?
The study is being done by Communities for a Better Environment (CBE), a non-profit environmental health and justice organization; Silent Spring Institute, a non-profit research organization that studies women's health and the environment; and Brown University. The National Institute of Environmental Health Sciences is sponsoring the research.

WHO IS IN THE STUDY AND HOW IS THE STUDY BEING DONE?
We invited residents from the Liberty and Atchison Village neighborhoods in Richmond and from Bolinas to participate in the study. A total of 50 homes are in the study: 40 in Richmond and 10 in Bolinas. Researchers collected air and dust samples from each home and from outdoor areas nearby, and they interviewed participants about the types of household products they use. The air and dust samples will be tested for more than 100 chemicals that are in consumer products or air pollution. By collecting samples in Richmond and Bolinas, we will be able to compare homes near air pollution sources with homes in a more rural area.

WHAT CHEMICALS IS THE STUDY TESTING FOR?
Metals and particulate matter. Because the Richmond homes in this study are close to industries, such as the Chevron refinery, and to pollution from highways, rail lines, and ship lanes, the study is sampling chemicals associated with those sources, such as metals and particulate matter (small dust that you can breathe into your lungs). These pollutants can affect asthma, other respiratory diseases, and heart health.
Chemicals that may affect hormones. Other chemicals were chosen for this study because of evidence that they may affect hormones. These are known as endocrine disrupting chemicals (EDCs). Some of these chemicals mimic estrogen. They are found in common products, including some pesticides, cleaning products, plastics, furniture, and cosmetics. Exposure to the natural estrogen made in our bodies increases breast cancer risk, so learning about exposure to other chemicals that mimic estrogen may one day help us learn ways to prevent breast cancer. The chemicals that affect hormones may also affect asthma, fertility, child development in early life and at puberty, learning disabilities, and other aspects of health.
Exposure is an environmental justice concern because low-income communities often have higher asthma rates. Also, African-American women are more likely than others to be diagnosed with breast cancer at an early age and more likely to die of it, even if they have good access to medical care.

WHAT WILL THE STUDY RESULTS SHOW?
Study results will tell us the levels of the chemicals that are found in homes in Richmond and Bolinas. We will be able to compare homes in these two communities with each other and with results from other studies, including homes we tested in Massachusetts.
In this study, we will not be able to draw conclusions about the health effects of exposure to the chemicals. Further studies would be needed to determine any link between the pattern of exposure and its health consequences.

HOW WILL RESULTS BE REPORTED?
Individuals who participated in the sampling will have an opportunity to see results for their home if they want to. Summaries of the findings for the communities as a whole will be reported in public meetings and news media as the analysis is completed. The results will also be published in scientific journals. No information that links the personal identity of anyone in the study with the results will be published or shared; individual information will be kept confidential. Right now the laboratory chemical analyses and statistical analyses are in progress. Because this study will yield a great deal of information, additional results will continue to be reported over several years.

HOW CAN I GET MORE INFORMATION?
Please feel free to contact CBE study coordinator Jessica Tovar or Carla Perez at 510-302-0430.

Hoja Informativa del Estudio Sobre la Exposición en el Hogar ¿CUÁL ES EL PROPÓSITO DEL ESTUDIO?
La mayoría de la gente pasa la mayor parte de su tiempo en la casa así que los químicos a los cuales están expuestos las personas en su casa pueden ser importantes para la salud. Estamos estudiando químicos que provienen de actividades dentro del hogar así como contaminantes que pueden provenir de fuera. La meta es aprender sobre las pautas de exposición dentro del hogar. También estamos tratando de aprender cómo reducir las exposiciones dentro del hogar.

¿QUIÉN HACE EL ESTUDIO?
El estudio lo hace Communities for a Better Environment (CBE) (Comunidades Para un Mejor Medioambiente), una organización sin fines de lucro para la salud y justicia medioambiental; Silent Spring Institute, una organización sin fines de lucro que estudia la salud de las mujeres y el medioambiente; y la Universidad Brown. El Instituto Nacional de Ciencias de la Salud Medioambiental está patrocinando la investigación.

¿QUIÉN PARTICIPA EN EL ESTUDIO Y CÓMO SE ESTÁ HACIENDO EL ESTUDIO?
Invitamos a residentes de los vecindarios de Liberty y Atchison Village en Richmond y de Bolinas a que participaran en el estudio. Un total de 50 hogares están participando en el estudio: 40 en Richmond y 10 en Bolinas. Los investigadores recogieron muestras del aire y del polvo de cada casa y de las zonas exteriores cercanas y entrevistaron a los participantes sobre los tipos de productos para el hogar que usan. Las muestras del aire y del polvo se analizarán para ver si contienen uno o más de los 100 químicos que se encuentran en productos del consumidor o en la contaminación del aire. Al recoger las muestras en Richmond y en Bolinas podremos comparar las casas que están cerca de las fuentes de contaminación del aire con casas que están en zonas más rurales.

¿QUÉ MOSTRARÁN LOS RESULTADOS DEL ESTUDIO?
Los resultados del estudio nos dirán los niveles de los químicos que se encuentran en los hogares de Richmond y Bolinas. Nos permitirán hacer comparaciones entre hogares de estas dos comunidades y con los resultados de otros estudios, incluyendo hogares que analizamos en Massachussets. En este estudio no podremos sacar conclusiones sobre los efectos de la exposición a los químicos en la salud. Se necesitarían más estudios para determinar el vínculo que existe entre el modelo de la exposición y sus consecuencias médicas.

Household Exposure Study Chemicals
Chemical group Environment and health

Pesticides
Example: chlordane Sources include disinfectants, weed and bug killers used in or near the home, and drift from commercial and agricultural activities.
Can cause many types of health effects, including effects on brain and reproductive system development and function, hormone systems, ability to fight disease, cancer, and kidney and liver function.

Phthalates
Example: dibutyl phthalate Can be found in vinyl and other plastics, such as children's toys; and also in nail polish, hair spray, and other cosmetics.
Have been shown to affect hormone systems and cause reproductive harm, especially from exposure during pregnancy.

Flame Retardants
Example: PBDE 47 Can be found in children's sleepwear, foam furniture and cushions, mattresses and pillows, synthetic carpets and drapes, and electronic equipment (TVs, computers).
Have been shown to affect hormone systems and thyroid hormones and cause reproductive harm and effects on learning and behavior in animal studies.

PCBs
Example: PCB 52 Sources include older electrical equipment and building materials such as caulks and paints. Banned from new uses in the 1970s but still commonly detected indoors and out.
Can cause effects on brain development, thyroid hormones, reduced ability to fight disease, hormone disruption, liver damage, and cancer.
Se ha mostrado que afecta los sistemas hormonales y las hormonas de la tiroides y causa daño reproductivo y tiene efectos en el aprendizaje y la conducta de los animales según los estudios.
Se ha mostrado que afecta los sistemas hormonales en los animales según los estudios.
Puede causar problemas de respiración e irritación de la piel y los ojos.

¿CÓMO PUEDEN LOS QUÍMICOS ENTRAR EN MI CUERPO?
Los químicos pueden entrar en su cuerpo cuando respira, come y bebe, y por la piel. Los químicos también pueden ser pasados de las madres a los bebés por medio de la placenta y la leche materna.

Ants Ants
How baits work: Pesticide baits attract worker ants so they will take it back to the nest where the entire colony, including queens, may be killed. The pesticide must be slow acting so workers won't be killed before they get back to the nest.
How to use baits: Place baits near ant trails and nest openings. Prepackaged or refillable bait stations or stakes are safest and easiest to use. Active ingredients in baits may include boric acid/borate, fipronil, avermectin, sulfluramid, hydramethylnon, or arsenic trioxide. Replace baits when empty and reposition them, or try a different bait product if ants don't appear to be taking it. It may take 5 to 10 days to see fewer ants.
Although ants are annoying when they come indoors, they can be beneficial by feeding on fleas, termites, and other pests in the garden. While spraying chemicals inside the house may seem effective, it won't prevent more ants from entering your home because most ants live outdoors. Instead, focus efforts on keeping ants from entering buildings. Combine several methods such as caulking entryways, cleaning up food sources, and baiting when necessary. Avoid the use of pyrethroids (e.g. bifenthrin and cypermethrin), especially on hard surfaces such as driveways, sidewalks, or around the foundation of buildings. These products pollute waterways.
Make your house less attractive to ants.

Cockroaches Cockroaches
Cockroaches thrive in warm environments that provide food, water, and shelter. Roaches hide in cracks, crawl spaces, and other dark places during the day and come out at night to feed. Pesticide sprays alone will not control roaches and are not usually required. Baits provide better control. You must integrate several strategies to make your home a less roach-friendly environment. Thoroughness is essential for effective control.

Identify your cockroach species first:
✦ Effective management options vary according to species. ✦ Cockroach traps provide an easy way to catch roaches for identification. ✦ Control practices for outdoor invaders (American, oriental roaches) and indoor residents (brown-banded and German roaches) differ. ✦ For help with identification go to www.ipm.ucdavis.edu Remove food and water sources:

Mercury
We tested for mercury. Mercury is a metal found in nature. It gets into the environment from coal burning, other industries, and abandoned gold mines. Mercury builds up in certain types of fish.
Did you find mercury in my blood?
Yes. We found mercury in your blood.
Did you find mercury in my baby's blood?
Yes. We found mercury in your baby's blood.
Can I compare our levels to other levels?
You can use the Results Chart and the Table in this packet to compare your mercury levels to: • Other mothers and babies in the study. We found mercury in every mother we tested. We found mercury in every baby we tested.
• National median. The national median is the middle level for pregnant women in the U.S. This means that half of U.S. pregnant women tested had mercury levels below the median, and half had levels above the median. Your mercury level was greater than the national median. The national median for mercury in babies is not known.
• Level of concern. Your mercury level was less than the level of concern. Your baby's mercury level was less than the level of concern.
The next page explains more about mercury.

More Information about Mercury
Mercury is found in • Certain types of fish and seafood.
• Some imported face creams used for skin lightening, anti-aging or acne.
• Glass thermometers, older barometers, and blood pressure gauges.
Possible health concerns • Mercury can affect brain development and cause learning and behavior problems in babies exposed in the womb and in children. • Mercury can harm the nervous system and kidneys. • Mercury may affect the heart.
Possible ways to reduce exposure • Choose fish that are lower in mercury, such as salmon, tilapia, trout, canned light tuna, sardines, anchovies, and oysters. • Avoid fish that are high in mercury, such as shark, swordfish, orange roughy, bluefin and bigeye tuna. • Do not use imported skin-lightening, acne treatment or anti-aging creams unless you are certain that they do not contain mercury. • Do not let children play with silver liquid from items such as mercury thermometers.

For More Information
Choosing fish that are lower in mercury: www.oehha.ca.gov/fish/pdf/2011CommFishGuide color.pdf Information on mercury in fish that you catch: www.oehha.ca.gov/fish/hg/index.html or call (510)  Your baby's level (There is no purple circle if we did not find this chemical in your baby's blood.)

Levels of other mothers or babies in the study (Each circle represents an individual in the study.)
National median (Half of U.S. pregnant women tested were above this level and half were below.) Level of concern (If your level is above this, we suggest ways to reduce your exposure.)

Concentration
Micrograms of lead in each deciliter of blood

List of Metals Tested
Explanation of terms: • National median: Half of U.S. pregnant woment tested were above this level and half were below. The national medians for babies are not known. • National 95% level: 95% of U.S. pregnant women tested had levels below this level. This means that in a group of 100 pregnant women, 95 had levels below this level. Only 5%, or 5 out of 100 pregnant women, had levels above this level. The national 95% levels for babies are not known. • Level of concern: If your level is above this, we suggest ways to reduce your exposure.

Metals We Tested in Your Blood
Metal tested Your level National median National 95% level Level of concern Number of mothers in this study with this metal in their blood

Summary of Results for You and Your Baby
Perfluorochemicals (PFCs) We tested for 12 PFCs. PFCs are used to make products that resist stains, oil, grease and water.
Did you find PFCs in my blood?
Yes. We found 7 PFCs in your blood.
Did you find PFCs in my baby's blood?
Yes. We found 8 PFCs in your baby's blood.
Can I compare our levels to other levels?
You can use the Results Chart and the Table in this packet to compare your PFC levels to: • Other mothers and babies in the study. We found PFCs in every mother we tested. We found PFCs in every baby we tested.
• National median. The national median is the middle level for pregnant women in the U.S. This means that half of U.S. pregnant women tested had PFC levels below the median, and half had levels above the median. Of the 7 PFCs we found in your blood, 1 was above the national median, and 4 were below. The national medians for the remaining 2 are not known. The national medians for PFCs in babies are not known.
• Level of concern. Levels of concern have not been set for PFCs.
The next page explains more about PFCs. PFCs are found in • Some foods, such as red meat and potato chips. Scientists are not sure which foods commonly contain PFCs. • Some grease-repellent paper food containers, such as some microwave popcorn bags, take-out boxes, or fast food wrappers. • Stain-resistant carpets and some carpet cleaning products. • Stain-resistant fabrics and sprays, and waterproofing sprays. • Most non-stick cookware.
Possible health concerns Scientists are still studying how PFCs may affect people's health. There is concern that some PFCs: • May affect the developing fetus and child, including possible changes in growth, learning and behavior. • May decrease fertility and affect hormone balance.
• May contribute to cancer.

Possible ways to reduce exposure
Scientists are not sure how best to reduce PFC exposures. However, you can: • Limit how often you eat foods from grease-repellent paper containers.
• Avoid buying carpets and other items that are labeled "stain-resistant".
• Avoid using waterproofing sprays and carpet cleaning solutions that contain PFCs.
For More Information PFC fact sheet: www.cdc.gov/exposurereport/PFCs FactSheet.html We tested for bisphenol A (BPA). BPA is used to make a hard plastic called polycarbonate. BPA is also used to make protective coatings, like the linings in metal food cans that prevent rust and corrosion.
Did you find BPA in my urine?
Yes. We found BPA in your urine. (We did not test babies for BPA.) Can I compare my levels to other levels?
You can use the Results Chart and the Table in this packet to compare your BPA levels to: • Other mothers in the study. We found BPA in most mothers tested.
• National median. The national median is the middle level for pregnant women in the U.S. This means that half of U.S. pregnant women tested had BPA levels below the median, and half had levels above the median. Your BPA level was greater than the national median.
• Level of concern. A level of concern has not been set for BPA.
The next page explains more about BPA. • The coatings inside food and drink cans.
• Some hard plastic food and drink containers, which might be labeled with the number "7" or "PC" on the bottom. • Some older plastic baby bottles and sippy cups. This use of BPA is ending and will be banned in California by 2013. • Some plastic stretch wrap used to cover or package food. • Some cash register receipts. • Dental sealants and white fillings.
Possible health concerns Scientists are still studying how BPA may affect people's health. There is concern that BPA: • May affect the fetus and infant, including possible changes in development and behavior.
• May affect hormone function.
• May affect reproductive function.
• May contribute to cancer.
Possible ways to reduce exposure • Eat more fresh food and less canned food.
• Use glass or stainless steel containers to store food and liquids.
• Avoid using plastic containers for hot food or drinks. Avoid microwaving plastic containers.
• Breast-feed your baby when you can. For bottle-feeding, use glass bottles.
• Wash hands before eating, because things you touch can have BPA in them.

For More Information
BPA fact sheet for parents: www.hhs.gov/safety/bpa/

Triclosan
We tested for triclosan. Triclosan is used to kill bacteria. It is added to soaps and other consumer products labeled as "antibacterial" or "antimicrobial." Did you find triclosan in my urine?
Yes. We found triclosan in your urine. (We did not test babies for triclosan.) Can I compare my levels to other levels?
You can use the Results Chart and the Table in this packet to compare your triclosan levels to: • Other mothers in the study. We found triclosan in most mothers tested.
• National median. The national median is the middle level for pregnant women in the U.S. This means that half of U.S. pregnant women tested had triclosan levels below the median, and half had levels above the median. Your triclosan level was greater than the national median.
• Level of concern. A level of concern has not been set for triclosan.
The next page explains more about triclosan.

More Information about Triclosan
Triclosan is found in • Most antibacterial liquid hand soaps and some antibacterial bar soaps.
• Many consumer products, such as some cutting boards, toys, clothes, towels, paint, and garden hoses.
Possible health concerns Scientists are still studying how triclosan may affect people's health. There is concern that triclosan: • May affect hormone function.
• May make it harder for antibiotic medicines to fight infections in the body. This is because overuse of triclosan may cause changes in bacteria that make them harder to kill.
Possible ways to reduce exposure • Use regular soap and water to wash your hands. This is just as effective as antibacterial soap.
• Avoid products that contain triclosan, unless you have a medical reason for using them.

List of Phenols Tested
Explanation of terms: • National median: Half of U.S. pregnant woment tested were above this level and half were below. • National 95% level: 95% of U.S. pregnant women tested had levels below this level. This means that in a group of 100 pregnant women, 95 had levels below this level. Only 5%, or 5 out of 100 pregnant women, had levels above this level. • Level of concern: Levels of concern have not been set for phenols. • Many cleaning products can be sources of respiratory irritants, carcinogens, and endocrine disrupting compounds (EDCschemicals that can mimic or disrupt hormones).

Phenols We Tested in Your Urine
• Household dust can harbor pollutants such as pesticides, flame retardants, and other chemicals; and allergens.

KEEPING DUST LEVELS LOW Vacuum
Avoid recycling dust back into the air by choosing models with strong suction, rotating brushes, brush on/off switch, a multi-layered bag for dust collection, and a HEPA (high efficiency particulate air) filter. Remember to clean and change the vacuum filter often.

Use a door mat
Pollutants can enter your home on the bottoms of your shoes and on the paws of your pets. To minimize the spread of these pollutants, place a doormat on the outside of each entrance to your home and a washable rug on the inside of each entry; and leave your shoes at the door.

CHOOSING LESS TOXIC CLEANERS
Although some cleaning products are labeled "natural," "green," or "non-toxic," the terms do not necessarily mean the products are safe. Reading the label is the first step; however, because manufacturers do not have to list all ingredients, it isn't always helpful. Silent Spring Institute is currently testing a range of products to identify safer choices. At this stage, here are some guidelines to keep in mind when choosing products: • Choose mainly plant-based ingredients • Avoid phthalates (chemicals used to carry fragrance) by reading the label or choosing "fragrance-free" • Avoid anti-bacterials (e.g., triclosan, Microban) in dishwashing liquid, hand soap, toothpaste, and clothing • Avoid dichlorobenzene (disinfectant for toilets, garbage cans, and diaper pails) • Avoid alkylphenol ethoxylates (APEs) in detergents and all-purpose cleaners • Avoid ethanolamines (e.g., monoethanolamine (MEA), diethanolamine (DEA)) in detergents, all-purpose cleaners, and floor cleaners Tip: Prevent your shower from clogging by using a drain trap to catch hair.

MAKING YOUR OWN CLEANERS
Furniture Polish 1/4 cup olive oil 1/4 cup white distilled vinegar 20-30 drops lemon essential oil (2 teaspoons lemon juice may be substituted for lemon oil, but polish must then be stored in refrigerator) Shake well before using. Dip a clean, dry cloth into the polish and rub wood in the direction of the grain. Use a soft brush to work the polish into corners or tight places. • Muchos productos de limpieza pueden ser fuentes de irritantes respiratorios, cancerígenos y compuestos disruptores endocrinos (EDCs -químicos que pueden imitar o perturbar las hormonas). • El polvo doméstico puede contener contaminantes como pesticidas, retardadores de fuego, y otros químicos; así como también alergénicos.
Use un tapete a la entrada de su casa Los contaminantes pueden ingresar a su casa en las suelas de sus zapatos y en las patas de sus mascotas. Para minimizar la propagación de estos contaminantes, ponga un tapete en la parte de afuera de cada entrada de su casa y un tapete lavable en la parte interior de cada entrada; y deje sus zapatos en la puerta.