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

Abstract

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

asbestos, community exposures, housing, immigrant health, lead, occupational health disparities, paraoccupational, pesticides, precarious labor, take-home, work

Introduction

Although pediatricians and epidemiologists are increasingly likely to consider the influence that a parent’s occupation has on the health of their children, population-level research characterizing the pathways by which this happens remains nascent, sparse, and focused on singular cases. The take-home pathway—in which a worker contaminates shared family spaces with toxic exposures that have been tracked home from the workplace—serves as an intriguing example of how occupational conditions can have broader public health consequences.

Conceptualization of take-home (or paraoccupational) exposures has emerged slowly from reports of specific poisoning events, as in the case of childhood lead poisoning related to occupation of coinhabitants (CDC, 2012, 2015), or from health concerns among children in rural communities exposed to pesticides from agriculture (Suarez-Lopez et al., 2012; Fenske et al., 2013; Suarez-Lopez et al., 2018). Most research has focused on the behavior of workers and family members in isolation without explicitly considering the larger social structures and power relationships that influence this behavior. Current descriptions of the take-home pathway rarely consider it as emerging from determinants of its own within certain social contexts. Understanding take-home exposures through an ecosocial lens (Krieger, 2010) may help explain their complex origin as a product of behavior by multiple factors in the workplace and at home. Thus, the take-home exposure pathway may contribute to known health disparities in marginalized populations that are reliant on precarious labor. This echoes calls in the literature for a biosocial approach to medicine (Farmer, 2002; Farmer et al., 2006), which broadens the reductionist view of cause and effect by grounding occupational exposures and injuries in their social context and the life course of workers and communities (Leong et al., 2014; Peckham et al., 2017; Schulte et al., 2017; Flynn et al., 2018; Unterberger, 2018).

Given ongoing changes in both worker populations and the nature of work itself (Howard, 2017), a broader conceptualization of the take-home pathway would benefit from a more explicit inquiry into its social dimensions. A recent generalizable model of the take-home process indicates factors such as the extent of external workplace exposure and the amount to which these exposures are internalized and then spread by the worker (Jones and Burstyn, 2018). However, assigning key take-home factors at the level of the worker and worksite exclusively has the potential to ignore the impact of related macroeconomic processes, social dimensions, and policy environments that contribute to the problem. Given that structural vulnerabilities in workers often overlap (NIOSH/ASSE, 2015) and affect workplaces and homes alike, understanding the complexity of the take-home exposure issues requires a broader inquiry on root causes of the problem.

The objectives of this review article are to: (i) describe the history and variety of take-home contaminants studied, (ii) argue that the current approaches to study take-home exposures should expand beyond worker responsibility to include the worker’s ecosocial context, (iii) summarize the key structural vulnerabilities experienced by the populations most at risk for take-home exposures, and (iv) discuss the inclusion of these social factors in future take-home exposure research and prevention efforts. This review article will focus exclusively on chemicals and particulate/fiber contaminants, although acknowledging that there are psychosocial and biological hazards from the workplace that could be also taken home.

History of research on take-home exposures

By the 1970s, environmental health experts began noticing unusual cases of heavy metal poisonings and malignant mesotheliomas in the family members of industrial workers that had been exposed to lead dust or asbestos. Asbestos from industrial sources was found to contaminate the homes of workers (Anderson et al., 1976) and marriage to an asbestos-exposed worker was shown to be the single greatest risk factor in the development of mesothelioma apart from personal exposure at work (Vianna and Polan, 1978). Radiological studies confirmed that family members within these households developed significantly impairmented lung function compared to controls from the same communities (Anderson, 1979). Similarly, homeowners with high lead levels in their workplace had generally higher lead dust levels in their homes (Vostal et al., 1974),with their children being found to have higher blood lead levels (BLLs) (Baker et al., 1977; Dolcourt et al., 1978; Rice et al., 1978; Dolcourt et al., 1981; Kaye et al., 1987, Piacitelli et al., 1997; Roscoe et al., 1999; Aguilar-Garduño et al., 2003). Even though adults in the home or workplace may remain unaffected by contaminants, dust in homes and automobiles was highlighted as a particularly salient pathway for childhood exposure due to hand-to-mouth pathways (Borsnchein, 1985; CDC, 2009a; Boraiko et al., 2013).

Evidence of population impact from take-home exposures grew, with numerous studies showing children of lead-exposed workers about 5–7 times as likely to have BLLs of >10 µg dl⁻¹ than controls (Whelan et al., 1997; Roscoe et al., 1999). Children were found with BLLs well above 10 µg dl⁻¹ shortly after their parents worked with lead-treated paint and lumber in construction while not informed of potential hazards (CDC, 2001; 2009a). In the cases of both lead and asbestos, worker hygiene controls effectively reduced a family member’s exposure, particularly showering and laundering clothing at work (Rice et al., 1978; Morton et al., 1982; Whelan et al., 1997).

Although research on lead and asbestos continued, the topic of take-home exposures expanded through the 1990s and 2000s to consider other contaminants and industries. Hawaiian families working in lumber processing have been studied due to the extremely high levels of arsenic dust found in their homes (Knishkowy and Baker, 1986). Parental occupation in construction was also associated with childhood cancers, highlighting the possibility of chronic low-level take-home exposure to solvents and hydrocarbons during developmental periods (Savitz and Chen, 1990; Moore et al., 2005). Take-home of pesticides (primarily organophosphates) via agricultural workers has been well documented, starting in the mid 1990s (Simcox et al., 1995). Apart from consistently high levels of organophosphates in the homes of workers (Simcox et al., 1995; Lu et al., 2004) and high metabolite levels in the urine of their children (Lu et al., 2000), take-home exposure has been correlated with decreases in acetylcholinesterase (AChE) activity (Suarez-Lopez et al., 2012; Suarez-Lopez et al., 2018) and neurocognitive impairment on math and language tests in children and adults (Rohlman et al., 2005; Wang et al., 2016a; Waheed et al., 2017). Children are particularly affected by overlapping cumulative exposures in these settings, with decreasing AChE activity correlated with an increasing number of potential pathways through which a child can be exposed (Suarez-Lopez et al., 2012).

Other documented take-home contaminants include beryllium (Sanderson et al., 1999), manganese (Gunier et al., 2013), swine influenza (Gray et al., 2007), and toluene diisocyanate (a monomer used in the production of polyurethane foam) (McDiarmid and Weaver, 1993). The children of bakers have been shown to have a higher risk of developing asthma and allergies in ecological studies, possibly due to wheat sensitization induced by the flour their parents tracked home (Vissers et al., 2001; Tagiyeva et al., 2010; Fishwick et al., 2011; Tagiyeva et al., 2012).

In recent years, take-home exposure issues persist. The proportion of mesothelioma cases due to take-home of asbestos fibers from industrial and construction sites has risen as other sources of exposure have fallen (Goldberg et al., 2009), and one source estimates the take-home pathway amounted to 20% of the mesotheliomas diagnosed in Canadian females in 2011 (Tompa et al., 2017). Take-home pathways have been increasingly better defined, sometimes showing multiple exposures within single industries. Electronics waste (e-waste) and battery recycling have gained attention in recent years as examples of take-home lead exposures in emergent small industries due to the absence of enforced hygiene standards (CDC, 2012; Chen et al., 2011; Wath et al., 2011; CDC, 2015; Ceballos and Dong, 2016). However, electronics waste recycling generates hazards beyond lead alone, and polychlorinated biphenyl compounds (PCBs) have been tracked from recycling facilities in China to workers’ homes (Wang et al., 2016b).

Fouling one’s nest or environmental injustice? Cumulative hazards and the role of work

Early reviews of the pathway likened take-home exposures across industries to a ‘fouling of one’s nest’ (Chisholm, 1978), in which uninformed industrial workers were oblivious to the dangers of inadequate hygiene, a definition which was later expanded to include industrial activities performed within the home (or ‘cottage industries’) (McDiarmid and Weaver, 1993). While this description may be partially true, history suggests it to be overly facile and incomplete. This emphasis on worker knowledge and behavior leaves out the social contexts that structure risky work, the implementation of protective measures, and toxic home environments. Furthermore, it positions work as a domain that is separate from the domestic—an ideal that overlooks the very real vulnerabilities that become part of a family’s daily life when they are singularly dependent on unstable, low paid, dirty, or even demeaning work. The metaphor exclusively blames a caregiver as it conjures up an image of a nesting animal acting on rote instinct—choosing to go outside and, in their ignorance, bringing toxic materials back inside. Yet it fails to describe the feasibility of building an appropriate, protective nest in a consistently insecure and poisonous environment. While the distinction of work/nonwork has played a central role in the evolution of occupational health, the example of take-home exposures highlights the limitations of this forced and artificial dichotomy (Peckham et al., 2017; Schulte et al., 2017; Flynn, 2018). This has been evident since the first explanation of the take-home pathway was subsequently amended to include poisonings that stem from cottage industries, demonstrating that those who labor under extreme social and economic pressures often find that their work both supports and endangers domestic life (Matte et al., 1989; McDiarmid and Weaver, 1993; Aguilar-Garduño et al., 2003; Untimanon et al., 2011).

Social and economic pressures at the individual worker level are rarely called out by name in the take-home exposure literature, nor are they measured or placed within historical and macroeconomic contexts. Workers experiencing take-home contamination often work in precarious, temporary, or seasonal positions (Whelan et al., 1997; Thompson et al., 2014), for low pay (Quirós-Alcalá et al., 2011) or in contexts marked by rapid urbanization, low community status, and low education rates (Maharachpong et al., 2006; Thanapop et al., 2009; Waheed et al., 2017). They often work in industries structured by global trade that maximizes profits while exporting hazardous work to places with cheaper and/or unprotected labor (Tsydenova et al., 2011; Suarez-Lopez et al., 2018). Worker communities also often experience language barriers with employers and broader society (Thompson et al., 2008), and work in areas with rare or nonexistent community-based training of healthcare professionals (Beitz and Castro, 2010; McLaurin and Liebman, 2012). In many cases, those most affected are children of a migrant workforce, such as agriculture and construction in high-income countries (Kar-Purkayastha et al., 2012; Arcury et al., 2014). A prime example can also be found in the emergent e-waste industry, where an international, loosely regulated market (Tsydenova et al., 2011) with inconsistent safety precautions (Bakhiyi et al., 2018) and fragmented data on its environmental impact (Tsydenova et al., 2011) is likely leading to many child-specific toxic pathways (Chen et al., 2011; CDC, 2015).

Structural vulnerabilities and populations at risk of take-home exposures

Many years have passed since asbestos, lead, and other take-home contaminants were first detected and determined to be easily preventable through adequate occupational hygiene and policy. Yet the phenomenon persists across a wide range of industries, where prevention is challenged even in the presence of occupational legislation to mitigate chemical exposures in the workplace. Research on take-home exposures should inherently complicate the strict dichotomy between the workplace and home by focusing on how harmful behaviors and poorer health outcomes can stem from a combination of working environments and persistent structural vulnerabilities.

Apart from the specific exposures and industries that have been detailed in the literature, research on these exposures is often conducted on populations that are most frequently affected, implying key structural vulnerabilities. In this review article, we discuss specifically: workplace discrimination, immigrant labor, precarious work arrangements, and community marginalization, with an additional focus on the children and domestic partners of workers. These vulnerabilities are outlined within a proposed conceptual model of take-home exposure factors displayed in Fig. 1.

Figure 1.

Conceptual model of workplace, home, and community-level factors that allow for take-home exposures.

This model forms the basis of an ecosocial approach to take-home exposures. Ecosocial theory centers the question of who is at risk of take-home exposures within the embodiment of material and social conditions, while acknowledging the cumulative interplay between exposure, susceptibility, and resistance (Berkman, 2014). This allows the perennial problem of take-home exposure related illness to be reframed as a question of who works and lives under which circumstances, and the reasons why. This review will flesh out the context in which worker behaviors occur, deriving a better structural understanding of how risk is created and distributed along the take-home pathway. The structural vulnerabilities discussed in this analysis are empirically derived from case studies and research within specific populations, though there are likely a broader set of vulnerabilities and populations affected.

Each vulnerability stems from a lack of power in the workplace or broader society, resulting in conditions that heighten a group’s risk or suggest that multiple exposures accumulate in the home. In the reviewed literature, take-home exposures primarily affected racial or ethnic minority, young, low-income, temporary, or immigrant workers and their families. However, under the ecosocial theory, one could expect that any marginalized and disempowered worker may struggle to secure safe housing and employment and could face similar structural vulnerabilities (formerly incarcerated workers for example). These vulnerabilities overlap and form a continuum of risk, unevenly distributing the impacts of hazardous work based on a system of advantages and disadvantages. As such, this model emphasizes that occupational and environmental health policy and enforcement must be considered through a viewpoint of accountability and justice, and worker-centered interventions should promote empowerment while factoring in social conditions.

Workplace and industry vulnerabilities

Workplace discrimination and the power to establish safe workplaces

Although examples of discrimination in the workplace have been well documented, it is less common for population research to identify common pathways through which these injustices manifest in health conditions (de Castro et al., 2006; Krieger et al., 2010). A better understanding of the take-home exposure pathway has the potential to contribute to this goal, given the structural marginalization of the groups that are most commonly affected. Take-home exposures could persist in situations where workers are in fact aware of workplace hygiene, but do not know their rights to access protective measures or feel that they cannot advocate for safer conditions or better training (OSHA, 2015). These problems may be aggravated if the workplace is marked by discrimination or language barriers (NIOSH/ASSE, 2015). Workers may fear any actions that require or draw legal attention if they are not citizens (Flynn et al., 2015; OSHA, 2015), and this fear can be exploited by comparatively powerful employers.

Small businesses that hire marginalized workers may take on workers who are at higher risk of occupational hazards, without themselves having the knowledge or resources to prevent them (NIOSH/ASSE, 2015; Cunningham et al., 2018). As large corporations increasingly outsource their most dangerous and contaminated work, these small companies can act as a repository of risks within a specific industry (Weil, 2014). Some industries may be more affected than others, such as those in the services sector, construction, and agriculture, which have a larger number of small businesses or outsource high-hazard tasks. Outdated exposure standards can leave industries and localities without the choice to enact effective protections (Shaffer and Gilbert, 2018). If worker communities have low political power, managers may feel little pressure to change policies to improve worker protections. Any consideration of take-home exposures should take these social dynamics as a reality in structuring access to a safe workplace, sometimes following a social hierarchy that deems some workers as less of a priority than others.

Immigrant labor

Economic immigration may also contribute to take-home pathways, as many cases collected in the literature occur within immigrant communities. Research shows that migration can influence the health of those that migrate, those who stay behind, and those that return to their country of origin (Flynn et al., 2014). Notably, immigrant workers often fill the demand for the dirty, demanding, and dangerous jobs (the ‘3Ds’) that are likely to cause occupational exposures (Connell, 1993). Undocumented immigrant workers in the United States are overrepresented in farming (26%) and construction (15%) jobs compared to their share of the workforce (5%) (Passel and Cohn, 2018), suggesting a concentration in environments primed for take-home exposures. Hazardous working conditions of undocumented parents often remain invisible to monitoring systems, and children of these immigrants (a majority of whom are U.S. Citizens) often remain invisible to insurance and quality healthcare (Ybarra et al., 2017). Given that work and immigration status strongly structure an immigrant family’s household and neighborhood conditions, multiple hazards that stem from the workplace may be more salient for children in immigrant homes.

Structural vulnerabilities can overlap within industries: undocumented workers younger than 25 are at particular risk of occupational injury when employed by small construction firms (NIOSH/ASSE, 2015; Cunningham et al., 2018). Although immigrant groups are sometimes healthier than the general populations of either their home or destination countries, their families often report poorer health with each generation (Teruya and Bazargan-Hejazi, 2013). The relationship between work-driven economic migration and health suggests that root causes of disease are shared between a variety of migrant groups, industries, and exposures. However, an expanded appreciation of occupational health promotion could leverage the worksite to promote healthier conditions that spillover into immigrant communities (Flynn and Wickramage, 2017).

Precarious work arrangements

While discrimination or immigration status may make employment more precarious, trends in precarious work are also distinct from these factors. After the 1980s, the labor force segmented into a comparatively high-paid core and a lower-paid, more interchangeable margin (Benach and Muntaner, 2007). The core retained the traditional employer benefits that accompany full-time labor, while the expanding margin adopted a ‘flexible’ or ‘precarious’ model of multiple contracts without benefits (which are sometimes mediated through an agency) (Benach et al., 2007). Recent estimates suggest that nonstandard work relationships represent between 8 and 18% of the total workforce, with the RAND-Princeton Contingent Work Survey highlighting a 5.7% increase in their estimate in 2015 (GAO, 2015; Katz et al., 2016). Nonstandard work arrangements are distributed unevenly, with immigrants and racial minorities being overrepresented in contingent work arrangements (Quinlan and Bohle, 2004).

Labor laws have not adapted to these changes in the labor force. Gaps in protection proliferate as a result, and the cost of injury has shifted from industry to families and taxpayers (OSHA, 2015). Under the Occupational Safety and Health Administration (OSHA), temporary employers and staffing agencies share safety responsibilities, but in practice this often leads to low adoption of protective equipment and training due to confusion over who should bear these costs for a transient workforce (OSHA, 2015; Howard, 2017). Independent contractors are considered responsible for their own safety and may not be covered under OSHA law. Workers have increasingly been reclassified (or misclassified) as independent contractors (Howard, 2017), particularly in many of the industries responsible for take-home exposures. A recent study estimated as many as 500 000 construction jobs in 3 states had been misclassified (OSHA, 2015). Because temporary, ‘independent’ workers often perform the same work function alongside standard workers, epidemiological associations between job function and disease rates within industries can be attenuated on large studies or surveillance systems. If the work arrangement is not controlled for, vulnerable workers are mixed in with those covered under occupational health law (Howard, 2017).

In addition to inadequate protections, this postrecession shift away from full-time positions has been marked by dangerous working conditions and lower pay (Benach et al., 2014). Taken as a whole, Peckham et al., (2017) argue that these structural changes in work arrangement fundamentally change the nature of our understanding of risk. Temporary employees, particularly in construction, general industry, and agriculture, have been shown to have higher injury rates than that of their permanent counterparts, with a 2.24-fold increased risk of being injured within their first month of employment in one sample (Foley, 2017). This is compounded for immigrants, who often compete for jobs in the lowest tiers of this precarious, low-wage market (Benach et al., 2014). Temporary workers are about half as likely to report hazardous dust in the same jobs as permanent workers, perhaps due to a lack of training in identifying it (Foley, 2017). Combined with less frequent access to personal protective equipment (and the social capital to change hazardous conditions at work), this implies that temporary workers are at a heightened chance of being unknowingly exposed to a hazardous material that could be brought home to their families (Foley, 2017; Howard, 2017). Apart from direct hazards to the worker, precarious employment has been linked to material deprivation in their families housing, nutrition, and healthcare that is necessary for the healthy development of children (Benach et al., 2014).

Home and neighborhood vulnerabilities

Under ecosocial theory, it should be expected that the embodiment of disease due to take-home exposures is highest when workers are marginalized both in the workplace and the communities they live in as well (Krieger, 2010). Any inequalities in the workplace can be compounded when workers return home. If a worker belongs to a marginalized group, they may be more likely to live in a community structured by a history of segregation, economic deprivation, and unjust zoning or land-use planning, which create indoor environments that encourage childhood health disparities (Gee and Payne-Sturges, 2004; Adamkiewicz et al., 2011). Housing and neighborhood injustices create chronic exposures to lead or pesticides from many different sources at once (Lanphear et al., 1997; Landrigan et al., 1999; Dilworth-Bart and Moore, 2006; McLaurin and Liebman, 2012). At the same time, workplaces that contaminate the environment may affect whole neighborhoods or towns where they are located (CDC, 2012). If take-home exposures accumulate in parallel with other well-documented environmental disparities, this cumulative effect between workplace and community disparities should be understood and prioritized.

Individual worker and family vulnerabilities

Our model embeds individual factors at the level of the worker and effected family members within a socioeconomic context—accounting for variation in parties on both end of the take-home pathway. These factors help account for the distinct nature of who is most frequently affected by take-home exposures apart from other exposures that arise in the workplace—i.e. women and children in working-class or low-income families. In this manner, education emerges as a strong determinant; both of workers and their partners. Workplace training can help protect a worker individually, however family and community members may also benefit from training (Ceballos et al., 2019). This is implied by the earliest documented cases of take-home related illness, which were caused by the laundering of asbestos-laden clothes by the wives of workers. Although workers may receive training or protective equipment on the job, there is rarely an equivalent assumption that unpaid domestic labor can carry consequences and requires ‘workplace’ protections or training.

Apart from hand-to-mouth pathways, the children of marginalized workers may encounter additional structural vulnerabilities due to family conditions. For instance, the level of household contamination is often contingent on the behavior of caregivers such as laundry, cooking, and cleaning practices. Conditions such as stress, mental health disorders, or psychological impairment due to chemical exposures can be brought home from the workplace as well (Jones and Burstyn, 2018). These can be transmitted to family members by damaging relationships, family functioning, and caretaking. Furthermore, the extent to which certain workplace exposures translate to the internal dose of a child can be moderated by whether a child is breastfed (Jones and Burstyn, 2018). Each of these family factors—caretaking, breastfeeding, and supportive relationships—is heavily embedded in culture. As such, policy and interventions may benefit from addressing the support and resources available to caretakers in creating a healthy environment for child development.

Eliminating take-home exposures: a shift toward comprehensive prevention is needed

Take-home exposure prevention usually includes a simple set of worker hygiene standards that can be supported or hindered through public and organizational policy such as uniform laundry services, mandatory showering, and improved clothes storage options (Chisholm, 1978; Bradman et al., 2009; Salvatore et al., 2009; Fenske et al., 2013; Julander et al., 2014). Each of these options has reduced risk in isolated settings, yet the literature reflects a persistent search for effective and comprehensive prevention (Landrigan et al., 1999; Lu et al., 2000; Thompson et al., 2003; Thompson et al., 2008; Suarez-Lopez et al., 2012). Notably, these efforts are not mandatory under occupational health law and rarely consider ecosocial factors when voluntarily implemented. As it stands, groups at highest risk of take-home exposures may be least likely to benefit from current standards in occupational health policy and practice.

Effective prevention begins with a working model of who is susceptible to take-home exposures and the reasons why. The most recent general model of take-home exposures draws on the source–pathway–receptor tradition and identified key variables as (i) the extent of external workplace exposure, (ii) the amount to which these exposures are internalized and then spread by the worker, and (iii) problematic behavior changes, such as those acquired through solvent-induced encephalopathy or depressive behaviors brought on by job stress (Jones and Burstyn, 2018). While this model is novel for in its clarity and inclusion of psychosocial stressors, all three factors center the determinants of disease at the level of the worker (and potentially the worksite). This focus on behavior echoes previous calls to prevent the ‘fouling of one’s nest’ by considering the impact of harmful behaviors without explicitly including of macroeconomic processes, social dimensions, and policy environments that may structure these behaviors and contribute to the problem.

By integrating an ecosocial understanding of disease distribution, one can better understand why prevention has remained incomplete throughout time, usually for the least empowered workers. A better model explicates the role of take-home exposures in perpetuating health disparities, and considers the relationship between environmental and social exposures at multiple levels, in the vein of models described by Olvera Alvarez et al. (2018)). This approach allows for factors such as the historical and political components of setting environmental and occupational policy standards, their enforcement, and concurrent social vulnerabilities across the lifespan. It also draws on the strengths and resources that communities can draw on to resist disproportionate exposures, appreciating how culture can enhance prevention efforts for high-risk groups. Simplified and isolated approaches to prevention—while appealing—will continue to fall short.

Consider lead as an example. There are ongoing efforts to reduce childhood lead exposure under a continually lowering child’s BLL threshold for intervention (which is now 5 µg dl⁻¹) (CDC, 2020). Although the number of children with BLLs above population targets has fallen, racial and socioeconomic disparities persist (Wheeler and Brown, 2013). These populations experience accumulation from multiple pathways over their life course (Leong et al., 2014; Schulte et al., 2017), and disparities could result from even low-level, chronic pathways. However, risk assessments can over-rely on a single pathway, underestimating collective impact and crowding out room for community-based programming to reduce multiple exposures for children (Landrigan et al., 1999). The legal system prefers the ease of a single behavioral pathway, and often assigns responsibility for lead poisoning to low-income mothers for failing to protect their children (Fentiman, 2017).

The children of exposed workers are frequently screened due to an increased awareness of take-home exposures among pediatricians and occupational safety professionals (McDiarmid and Weaver, 1993), yet clinical approaches may reach an effective limit given that many of the families continue to experience barriers in accessing consistent, quality healthcare and other social resources (Gee and Payne-Sturges, 2004; McLaurin and Liebman, 2012; Flynn, 2018). Traditional surveillance also has limits, as it has traditionally underrepresented temporary workers (Savitz and Chen, 1990; Whelan et al., 1997; National Academies, 2018), non-English speakers, or workers without a telephone (Buckley et al., 1989). Simply put, clinical and behavioral interventions often fall short when implemented in isolation, particularly if they are not state-mandated, community-based, or lack an understanding of social conditions (O’Connor et al., 2014; Quandt and Arcury, 2017).

To achieve comprehensive take-home prevention that accounts for disparities, we propose a three-tier intervention approach including prevention efforts at the workplace, home, and community levels simultaneously (Fig. 2). Traditionally, take-home lead exposure interventions involve remediation after poisoned children have been identified and the occupational origin confirmed. A recent example includes a multiagency intervention due to childhood lead poisoning cases that were associated with parental occupation in a battery recycling facility and affected the community where facility was located and workers resided (CDC, 2012). These types of interventions—happening after health outcomes were identified—are defined as tertiary prevention and keep symptoms from progressing (Campbell and Osterhoudt, 2000).

Figure 2.

Proposed comprehensive approach toward take-home exposure prevention.

The next most common approach is primary prevention, which by definition reduces the occurrence of disease itself by intervening through policies to identify and reduce exposures in the workplace prior to any changes in health (Campbell and Osterhoudt, 2000). Examples of primary prevention efforts have been documented when reducing workplace sources of pesticides (Fenske et al., 2013) and lead (Virji et al., 2009; Rodriguez et al., 2010), and using traditional industrial hygiene controls before contaminants travel to workers’ homes. While these efforts can be tailored to industries, workplaces, and workers, they are generally focused on reducing workplace exposure sources across the entire population of all workers. Primary prevention is the most effective and proactive approach to preventing the most serious harms that can stem from worker exposures, but needs to be complemented by secondary and tertiary measures to address cases of heightened-exposure. As noted, those at the highest risk of encountering workplace exposures are more likely to experience multiple compounding hazards via the neighborhood or home, or experience concurrent social vulnerabilities that enhance their impact (such as language barriers in trainings or lack of quality medical care). Allocating resources at this level may help reduce the disparities that occur as a result. Furthermore, outdated workplace legislation allows for chronic exposures to accumulate and travel home even under occupational compliance (NIOSH, 2014), meaning that secondary and tertiary prevention are a realistic necessity. This is especially true for family run businesses or small industries were compliance oversight is less present or nonexistent.

The least common approach is secondary prevention efforts, wherein take-home exposures are proactively identified and addressed early-on. One example is a targeted community-based education effort with families to reduce take-home exposures in agricultural communities (Salvatore et al., 2009). More research on early identification and reduction of take-home exposures, expanding beyond pesticides and agriculture alone, is a prime area for growth in future research and may include: (i) biomonitoring for multiple take-home exposures in children, (ii) improving home protections to reduce contaminants tracked from the workplace combined with family training, and (iii) assessing health of workers and their families. High impact contributions would involve research questions related to the measurement and reduction of risk—allowing researchers to track group disparities. Our proposed model and recommendations for future research could also address health disparities stemming from other nonchemical take-home exposures that are taken home from work, such as psychosocial stressors.

Prevention benefits from the explicit inclusion of social vulnerabilities as barriers to the health of an entire worker’s family. Ecosocial theory provides a clear roadmap for considering workers beyond their behaviors, by recognizing that community, workplace, and policy factors contribute to population health at multiple levels (Krieger, 2010). However, the role of work is rarely meaningfully integrated in population health equity research (Ahonen et al., 2018). Therefore, successful approaches used by other realms of community health may be needed to address take-home exposures; for example, policy changes through broad stakeholder organizing and the mobilization of community health workers (Fig. 2).

State actions to address lead highlight promising practices that, when considering work as a social determinant of health, may help protect children from a variety of take-home exposures as a part of this comprehensive approach. For instance, some states have provided small grants to incentivize housing upgrades that particularly assist ailing communities, while working on universal lead screening (Child Trends, 2018). The creative use of Medicaid’s Early Periodic Screening, Diagnostic, and Treatment (EPSDT) benefits opens up more venues for low-cost lead screening initiatives, including through Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) offices, Head Start and Early Head Start programs, and School Based Health Centers (CDC, 2009b). These screenings can lead to a wealth of integrated data that allow for more cost-effective interventions in the future (Dickman, 2017). Notably, community-based screenings also reach children who are not traditionally ‘seen’ by clinical surveillance, particularly educational-based programming which is generally more open to children regardless of their immigration status than those in healthcare settings (McNamara, 2016). These efforts would thus benefit from a stronger inclusion of occupational health and safety in areas with marginalized workers and could provide valuable data for detection and prevention when multiple administrative systems are linked. Small grants can also be used to assist small businesses with implementing consistent safety measures, or to disseminate prevention information effectively through vulnerable networks (NIOSH/ASSE, 2015). Integrating occupational safety with community-level health initiatives can only pay dividends of improved health in the future.

Conclusion

A broad range of contaminants have been documented to be brought home from work, including metals, fibers, solvents, isocyanates, pesticides, and PCBs. These can contribute to a variety of serious illnesses. Cases of take-home exposure have emerged from many types of industries, including facilities with formal health and safety programs (e.g. smelters), small industries (e.g. construction), agriculture, and cottage industries (e.g. backyard e-waste recycling), and will continue to do so as new industries and contaminants emerge. Despite the shifting range of industries, contexts, and exposures that have been studied, there seems to be a persistent pattern of who is disproportionately affected by take-home exposures: most often low-income or working-class women, children, and immigrants. Most research has focused on workplace behaviors and home environments as distinct, without including how both are structured in tandem by underlying social conditions. This has resulted in scattered detection of the problem and limited prevention methods. Research that considers how social determinants inform take-home exposures at both personal and macrolevels can help tailor more effective comprehensive prevention efforts for workers and their families.

Policies which encourage rapid increase in jobs for certain industry sectors, without adequate protections that prevent take-home exposures, may come with invisible costs for those with structural vulnerabilities in society (Siqueira et al., 2014). As such, occupational and environmental health professionals would benefit from applying lessons that have been learned through other community health initiatives, including stronger inclusion of paraprofessional community members in the occupational safety workforce, a focus on empowering workers, partnering with advocacy groups when enacting regulations, and the expansion of community-based screening and healthcare. Macrolevel changes may be required, such as mandatory take-home prevention training, better safeguards in the workplace regardless of working arrangement, updated exposure and hygiene standards, and more steadfast enforcement. These investments in achieving health equity should be expected to be complemented by other investments in workers’ communities.

The effective prevention of take-home exposures thus sits squarely within the elimination of multiple prioritized health disparities, including lead, pesticide, and other environmental exposures. As such, effective prevention should emphasize health equity through the creative application of community programming and public policy. Thus, in order to prevent the chronic, low-level, take-home exposures that are particularly harmful for developing children, a multitier intervention approach including interventions at the workplace, home, and community levels are needed. Effective prevention of take-home exposures may require interagency collaboration and the meaningful inclusion of community group representatives, creating stakeholder health task forces that focus on human health without drawing strict boundaries between the workplace and home. When public health and industry professionals cocreate policy and practices within communities, all parties have the potential to benefit long term from a healthy, sustainable workforce.

Funding

Funds were provided by pilot awards from the Harvard JPB Environmental Health Fellowship and the Harvard Chan and Boston University Schools of Public Health Center for Research on Environmental and Social Stressors in Housing Across the Life Course (CRESSH) (NIMHD P50MD010428 and the EPA 83615601-01). This work was also partially funded by the Harvard Hoffman Program on Chemicals and Health and National Institute of Health grant NIH/NIEHS 2R25ES023635-04.

Acknowledgments

The authors are grateful for the thoughtful review of this manuscript by Dr William Beckett.

Conflict of interest

The authors declare that there is no conflict of interest.

Disclaimer

The findings and conclusions in this article are those of the author and do not necessarily represent the views of the National Institute for Occupational Safety and Health.