Returning Biomonitoring Test Results in an Easy-to-Understand Format

This blog post is part of a biomonitoring series.

California passed novel legislation in 2006 that united three state departments in a new program called Biomonitoring California. These three departments—the California Department of Public Health, the Department of Toxic Substances Control and the Office of Environmental Health Hazard Assessment—are tasked with learning more about the chemicals found commonly in Californians, studying chemical trends over time and helping assess the effectiveness of current environmental chemical regulations.

“To address this legislation, we work very closely with our partners,” said Sandy McNeel, DVM, from California’s Department of Public Health. “We have different areas of expertise, so it is a very useful collaboration.”

The legislation defines “community” broadly with respect to biomonitoring studies. “Communities are not only geographically based, but also could be a group of pregnant women or a group who, because of their occupation, may have unusual exposure to certain chemicals,” said McNeel. Since inception, the program has initiated community-based studies of various types and collaborated with other researchers within state government and academia.

As these pioneering biomonitoring studies proceed, the state’s researchers are wrangling with an interesting facet of the law: they are required to return individual test results to all study participants who request them—in an easy-to-understand format.

While it may sound simple, it is very challenging to translate medical and laboratory research into straightforward English; or Spanish, as the case may be.

Still, the greater challenge is that no one, not even the scientists, really knows what some of the biomonitoring results mean in relation to human health. Whether a chemical causes health problems depends on how toxic the chemical is, how much a person takes in, and how long a person is in contact with the chemical.

Biomonitoring is a relatively new branch of laboratory science and new chemicals enter the marketplace every day. There are tens of thousands of chemicals in use today, many of which have not been studied throughly. Discovering possible health effects of chemicals can take years of research. Even with evidence that a chemical causes a particular health effect, it is difficult to know what level in people’s bodies would be harmful. Someone may have a high level of a chemical in her body and never have any effect from it. Another may have a similar level of the chemical and become ill, perhaps due to her genetic predisposition, an underlying health problem, other exposures, or additional unknown factors.

To help make all of this information clear to study participants, Biomonitoring California assembled a team that includes data analysts, chemists, epidemiologists, toxicologists, and health educators to identify what information would be useful to participants and how it should be worded or displayed for best effect.

After working through many versions of the results return format, the team field-tested it for feedback. The team simulated a set of biomonitoring test results and asked groups of volunteers from two ongoing studies to help refine it.

In one of those studies, the Firefighter Occupational Exposures (FOX) project, firefighters had been tested for a large number of chemicals, including some potentially dangerous flame retardants. The simulated results used in the testing process came with clarifying text, tables, graphs and a one-page fact sheet on each chemical or class of chemicals.

“We developed the materials to report results keeping in mind that the vast majority of study participants do not have a chemistry background or an understanding of what chemical exposure might mean,” said McNeel. “We spent quite a bit of time developing the text, thinking about the most understandable yet scientifically accurate way to describe the results.”

An individual can compare his or her results to others from the same study, as well as to data from the National Health and Nutrition Examination Survey (NHANES) when available. This way a study participant can see where he or she stands in relation to a representative sample of the United States’ general population.

After the simulated results were shared with the firefighters, a couple of the biomonitoring staff met with them to identify any points of confusion. The feedback led the team to add an explanation of why this community, in particular, was being studied and why the human health implications of most chemical exposures are still largely unknown.

Going forward, as results are returned to study participants, Biomonitoring California staff will follow up to see if people have a good understanding of the test results. “We tested, revised, tested, revised and still we consider these works-in-progress. We will continue to fine-tune the results return documents as we get more feedback from participants,” said McNeel.

McNeel added that, despite the results return team’s best efforts, some firefighters did express a degree of frustration about why they were being tested for chemicals if no one knows what the results mean. “Firefighters are an altruistic group of individuals,” she said. “We explained there just hasn’t been the research done to determine whether there are health effects associated with some of these chemicals and at what level health effects might start to occur. Some of our work is to help establish chemical levels in various groups so that we can compare and contrast them, and that this work will benefit future firefighters.”

Researchers with Biomonitoring California have found this design process rewarding. “All of us in the program really feel that it’s important for people to have a better understanding of chemicals in our environment,” said McNeel, “This is an area that deserves greater attention.”

To see an example of a results document, visit www.biomonitoring.ca.gov/sites/default/files/downloads/03162012FOXMockResultsPacket.pdf.

Without biomonitoring, public health practitioners face challenges in understanding whether environmental contaminants are actually being absorbed into people’s bodies. Given improvements in technology, the capabilities and expertise that exist in public health laboratories, and the increasing demand from the public for more information about chemical exposures, biomonitoring is poised to become an integral component of public health practice.

To learn more about biomonitoring, check out some of APHL’s Biomonitoring Resources: