Early environmental quality and life-course mental health effects: The Equal-Life project

O iginal Resea ch A icle
ISEE
ISEE
1
ENVIRONMENTAL
EPIDEMIOLOGY
Ea ly en i onmen al quali y and li e-cou se men al
heal h e ec s: The Equal-Li e p ojec
I ene anKampa,*, Ke s inPe sson Wayeb, Ka jaKanninenc, JohnGulli e d, Alessand oBozzone, AchilleasPsyllidise,
Hend iekBoshuizen , JennySelande g, Pe e  an den Hazelh, Ma coB ambillai, Ma iaFo as e j, Jo diJul ezk,
Ma iaKla el, SonjaJe amm, Pe e Le che n, DickBo eldoo eno, Go danaRis o skap, JaakkoKap ioq,
Di kSch eckenbe g , Maa enHo nikxs, JaninaFels , Mi iamWebe u, EllaB aa -Eggen , JuliaHa manna,
Cha lo eCla kw, TanjaV ijko ex, LexB owny, Gab ieleBol ez Equal-Li e Scien i ic Team**
In oduc ion
Men al heal h is one o he as es -g owing public heal h issues
in Eu ope p ima ily in e ms o awa eness. I s con ibu ion o
he bu den o disease weighs hea ily on socie ies and econo-
mies. In Eu ope, he cos o ill men al heal h was es ima ed o
be o e 4% o GDP in 2018.1 Those wi h ill men al heal h ha e
poo e educa ional and wo k ou comes han hose in good men-
al heal h. Men al heal h a a ( e y) ea ly age is a good p edic o
o a pe son’s wo k si ua ion in la e li e and a ailable esou ces
and accompanying adul men al heal h s a us. I is wo ying
ha a school age, one in en child en has a men al heal h p ob-
lem ha wa an s suppo and ea men .1
The e is inc easing e idence ha a complex in e play o ac-
o s in he en i onmen s in which child en g ow up con ibu es
o i e e sible men al heal h e ec s la e in li e.2,3 Es ima es o
he p e alence o ill men al heal h in adul s, due o di e en en i-
onmen al ac o s, a y s ongly be ween s udies, depending on
he ac o s conside ed.4 Child en a e e en a g ea e isk when
exposed o he same concen a ion o en i onmen al con ami-
nan s due o lowe smalle size and hei isk-inc easing beha -
io (e.g. hand- o-mou h con ac ) han adul s.5 Fu he mo e, wi h
apid b ain de elopmen in ea ly li e, en i onmen al exposu e a
ha age may esul in i e e sible e ec s on men al heal h and
cogni i e de elopmen .6 Despi e his, child en and adolescen s
ha e sys ema ically been unde s udied in his domain.
The exposome concep o e s a amewo k o s udy his com-
plex in e play. The exposome was in oduced i s ly in 2005
and la e expanded o emphasize he impo ance o human
Wha his a icle adds
Equal-Li e, as pa o he Eu opean Human Exposome Ne wo k,
ocuses uniquely on he e ec o he in e nal and ex e nal expo-
some on men al heal h and cogni i e de elopmen in child en,
wi h da a a ailable om concep ion o age 21 yea s. The disco -
e y o new bioma ke s o men al heal h and cogni i e de elop-
men has added scien i ic alue. T adi ional exposu es wi h a
nega i e heal h impac a e combined wi h ea u es p omo ing
heal h by a no el app oach o mul imodal exposu es. By includ-
ing a posi i e ou look on physical and social en i onmen s
Equal-Li e s imula es a mo e holis ic app oach o en i onmen-
al planning o di e en li e s ages and heal h equi y.
aCen e o Sus ainabili y, En i onmen and Heal h, Na ional Ins i u e o Public
Heal h and he En i onmen , Bil ho en, he Ne he lands; bSchool o Public
Heal h and Communi y Medicine, Go henbu g Uni e si y, Go henbu g, Sweden;
cA.I.Vi anen Ins i u e o Molecula Sciences, Uni e si y o Eas e n Finland,
Kuopio, Finland; dCen e o En i onmen al Heal h and Sus ainabili y & School
o Geog aphy, Geology and he En i onmen , Uni e si y o Leices e , Leices e ,
Uni ed Kingdom; eJoin Resea ch Cen e o U ban Sys ems and En i onmen ,
Del Uni e si y o Technology, Del , he Ne he lands; Cen e o Nu i ion,
P e en ion and Heal h Se ices, Na ional Ins i u e o Public Heal h and he
En i onmen , Bil ho en, he Ne he lands; gUni o Occupa ional Medicine a he
Ins i u e o En i onmen al Medicine, Ka olinska Ins i u e , S ockholm, Sweden;
hIn e na ional Ne wo k on Child en’s Heal h, En i onmen and Sa e y, Ellecom,
he Ne he lands; iDa a Science Labo a o y, Poli ecnico di Milano, Milan, I aly;
jBa celona Ins i u e o Global Heal h, ISGlobal, Ba celona, Spain; kIns i u
d'In es igació Sani à ia Pe e Vi gili (IISPV), Ba celona, Spain; lDepa men o
Cogni i e and De elopmen al Psychology, Technical Uni e si y Kaise slau e n,
Kaise slau e n, Ge many; mNa ional Ins i u e o Public Heal h, Ljubljana, Slo enia;
nIns i u e o Highway Enginee ing and T anspo Planning, G az Uni e si y o
Technology, G az, Aus ia; oDepa men o In o ma ion echnology, Facul y o
Enginee ing and A chi ec u e, Ghen Uni e si y, Ghen , Belgium; pIns i u e o
Public heal h o he Republic o No h Macedonia, Skopje, No h Macedonia;
qIns i u e o Molecula Medicine Finland, Depa men o Public Heal h, Uni e si y
Backg ound: The e is inc easing e idence ha a complex in e play o ac o s wi hin en i onmen s in which child en g ows up,
con ibu es o child en’s subop imal men al heal h and cogni i e de elopmen . The concep o he li e-cou se exposome helps o
s udy he impac o he physical and social en i onmen , including social inequi ies, on cogni i e de elopmen and men al heal h
o e ime.
Me hods: Equal-Li e de elops and es s combined exposu es and hei e ec s on child en’s men al heal h and cogni i e de elop-
men . Da a om eigh bi h-coho s and h ee school s udies (N = 240.000) linked o exposu e da a, will p o ide insigh s and policy
guidance in o aspec s o physical and social exposu es hi he o un apped, a di e en scale le els and ime ames, while accoun ing
o social inequi ies. Reasoning om he ou come poin o iew, ele an s akeholde s pa icipa e in he o mula ion and alida ion
o esea ch ques ions, and in he o mula ion o en i onmen al haza ds. Exposu e assessmen combines GIS-based en i onmen al
indica o s wi h omics app oaches and new da a sou ces, o ming he ea ly-li e exposome. S a is ical ools in eg a e da a a di e en
spa ial and empo al g anula i y and combine explo a o y machine lea ning models wi h hypo hesis-d i en causal modeling.
Conclusions: Equal-Li e con ibu es o he de elopmen and u iliza ion o he exposome concep by (1) in eg a ing he in e nal,
physical and social exposomes, (2) s udying a dis inc se o li e-cou se e ec s on a child’s de elopmen and men al heal h (3) cha -
ac e izing he child’s en i onmen a di e en de elopmen al s ages and in di e en ac i i y spaces, (4) looking a suppo i e en i on-
men s o child de elopmen , a he han me ely pollu an s, and (5) combining physical, social indica o s wi h no el e ec ma ke s
and using new da a sou ces desc ibing child ac i i y pa e ns and en i onmen s.
Kamp e al. • En i onmen al Epidemiology (2021) 6:e183 En i onmen al Epidemiology
2
en i onmen al exposu es.7,8 The concep e e s o he o ali y
o exposu es om a a ie y o ex e nal and in e nal exposu es
o e a comple e li e ime, om concep ion onwa d. I ein o ces
he idea ha heal h o disease is he p oduc o he indi idual’s
his o y o exposu es, esou ces, ulne abili y, and coping pos-
sibili ies. Resea ch on exposomes is acili a ed by echnologi-
cal de elopmen s ha complemen adi ional epidemiological
s udy designs.9 In his con ex , he s udies o he genome and
exposome in e sec , bu hey also di e ge because he exposome
is a a iable and dynamic en i y ha e ol es h oughou he
li e ime o he indi idual. Al hough he gene ic sequence is gen-
e ally unal e ed h ough he li e ime, he genome is dynamic and
exp esses i sel in a ange o bioma ke s. Pa o he changes
in he genome e lec s he a ia ion o he exposome, whe eas
pa o i e lec s de elopmen al gene ic p og amming, such as
g ow h and pube y.
Despi e he ac , ha social inequali ies in heal h a e a majo
public heal h challenge, and ha social inequali ies in housing
and en i onmen al condi ions also p e ail in Eu ope, un il now
he exposome concep s did no comp ehensi ely cap u e causes
o heal h inequi ies.10,11
Mo eo e , he social en i onmen is a c i ical dimension
in he p ocess o men al heal h and cogni i e de elopmen .
P e ious exposome concep s do no ully acknowledge he ele-
ance o he social en i onmen .12 On he o he hand, esea ch
linking he social en i onmen o child en’s men al heal h and
cogni i e de elopmen has la gely missed he a ie y o phys-
ical exposu es o e and abo e social posi ions o popula ion
g oups.13
Social and en i onmen al inequali ies o igina e a an ea ly
s age in li e and end o clus e oge he in child en om ami-
lies wi h low socioeconomic posi ion. Ea ly exposu es and hei
dis ibu ion along he social g adien can ha e se e al e ec s
on heal h in ela ion o childhood de elopmen in o adul hood.
Con e sely, a speci ic heal h p oblem is o en he esul an o
se e al ad e se exposu es ha o igina e om di e en sou ces
o which an indi idual is exposed in di e en ways and in di -
e en s ages o his o he de elopmen . Besides su e ing om
heal h e ec s o un ai en i onmen al and social condi ions,
child en om disad an aged socie al g oups migh be p one by
hei li ing con ex o unheal hy beha io s such as poo die ,
lack o physical ac i i y, and excessi e sc een ime, which acks
in o adul hood.14 Families wi h he low socioeconomic posi ion
a e mo e likely o maladap ed coping s a egies (smoking, alco-
hol use, and subs ance use) which ha e di ec p ena al and pos -
na al e ec s, as on he young child.15
Un a o able ac o s end o clus e oge he in child en
om amilies wi h low socioeconomic posi ion. Child en
g owing up in po e y a e exposed o a la ge numbe o
physical and psychosocial isk ac o s ac oss hei li e span
and ac oss mul iple se ings (a home, dayca e, school, and
neighbo hood).16 Howe e , despi e he g owing li e a u e
on neighbo hood e ec s and child de elopmen , his wo k
la gely equa es neighbo hood quali y wi h socio-economic
s a us (SES) while igno ing he po en ial ole o he physi-
cal quali y o neighbo hoods in a ec ing child en’s de elop-
men .17 A ecen e iew concluded ha u u e esea ch mus
also mo e deeply explo e he way child en and hei amilies
in e ac wi h hei neighbo hood and how his is shaped by
he a iabili y in neighbo hood cha ac e is ics, and i s con i-
bu ion o de elopmen al inequali ies.18
Compa ed o epidemiological s udies in adul s, ela i ely ew
s udies ha e inco po a ed longi udinal da a e alua ing child en
o e ime. I has been ound ha ch onic exposu e o mul i-
ple isk ac o s leads o di e ences in child en’s biological and
psychological egula o y sys ems, wi h low-income child en’s
ch onic s ess sys ems di e ing signi ican ly om hei pee s.18–
20 Poo e sel - egula ion, as e idenced by g ea e di icul ies wi h
a en ional con ol, delayed g a i ica ion, and inhibi o y con ol
has been associa ed wi h g owing up in po e y.3,21,22 Also in
high SES g oups delayed sel -con ol is an impo an p edic o
o nega i e heal h ou comes la e in li e.23 These maladap i e
coping s a egies a di e en unc ion le els ca y on la e in li e.
Di e ences in pa en ing in e ac ions a e associa ed wi h signi -
ican di e ences in child language and cogni i e de elopmen
ac oss he li e cou se.24 The associa ions a e sys ema ically he
esul o an accumula ion o mul iple isk ac o s which media e
he inal ou come. An unde lying assump ion is ha he physical
and social ci cums ances ha a child is b ough up in, a ec
p oximal p ocesses; ha is de elopmen p ocesses o sys ema ic
in e ac ion be ween a child and hei en i onmen s, needed o
op imal de elopmen .
The ole o media o s in his p ocess is only pa ly known,
bu sel - egula ion and maladap i e coping, neu ode elopmen ,
s ess, es o a ion, sleep, and physical and social suppo , a e
mechanisms iden i ied as po en ially impo an .25–27
These mechanisms a e ele an in e e y de elopmen s age,
bu hei e ec migh be e y di e en depending on age and
men al heal h ou come.
P ojec desc ip ion
Aim
Equal-Li e s udies he long- e m e ec s on men al heal h and
cogni i e de elopmen o he child-en i onmen in e ac ion.
En i onmen is b oadly de ined o include he physical, buil ,
social, economic and cul u al dimensions, and pe cei ed quali y
o place and li e.
Based on a pe son-con ex -p ocess- ime amewo k, Equal-
Li e add esses he mechanisms deemed ele an o he associ-
a ion be ween he exposome and child cogni i e de elopmen
and men al heal h.28,29
o Helsinki, Helsinki, Finland; Cen e o Applied Psychology, En i onmen al and
Social Resea ch (Zeus GmbH), Bochum, Ge many; sBuil En i onmen , Technical
Uni e si y Eindho en, Eindho en, he Ne he lands; Hea ing Technology and
Acous ics, RWTH Aachen Uni e si y, Aachen, Ge many; uCi y o U ech , U ech ,
he Ne he lands; A ans Uni e si y o Applied Science, Tilbu g, he Ne he lands;
wPopula ion Heal h Resea ch Ins i u e, S Geo ge's Uni e si y o London, London,
Uni ed Kingdom; xDepa men o Public and Occupa ional Heal h, Ams e dam
Public Heal h Resea ch Ins i u e, Ams e dam UMC, Ams e dam, he Ne he lands;
ySchool o En i onmen al Planning, G i i h Uni e si y, B isbane, Aus alia; and
zIns i u e o Public Heal h and Nu sing Resea ch, Uni e si y o B emen, B emen,
Ge many
**The membe s o “The Equal-Li e Scien i ic Team” a e lis ed in he Appendix.
The au ho s decla e ha hey ha e no con lic s o in e es wi h ega d o he
con en o his epo .
Only he esul s o Equal-Li e (e.g. agg ega ed da a no aceable o indi iduals,
algo i hms and scien i ic indings ele an o policy make s) will be made publicly
accessible and will be pa o he e idence-based guidance o be de eloped in
he p ojec .
All coho da a, school da a and sub-s udy da a used and collec ed in Equal-Li e
will s ay wi h hei owne s and will be linked o he exposome da a and will only
be agg ega ed a esul le el. The eby, we will ensu e ha all wo k ca ied ou in
Equal-Li e will comply wi h na ional law and comply wi h GDPR.
*Co esponding Au ho . Add ess: Cen e o Sus ainabili y, En i onmen and
Heal h,Na ional Ins i u e o Public Heal h and he En i onmen , he Ne he lands.
E-mail: [email p o ec ed] (I. . Kamp).
Copy igh © 2021 The Au ho s. Published by Wol e s Kluwe Heal h, Inc.
on behal o The En i onmen al Epidemiology. All igh s ese ed. This is an
open-access a icle dis ibu ed unde he e ms o he C ea i e Commons
A ibu ion-Non Comme cial-No De i a i es License 4.0 (CCBY-NC-ND), whe e i
is pe missible o download and sha e he wo k p o ided i is p ope ly ci ed. The
wo k canno be changed in any way o used comme cially wi hou pe mission
om he jou nal.
En i onmen al Epidemiology (2021) 6:e183
Recei ed: 9 Decembe 2020; Accep ed 14 No embe 2021
Published online 16 Decembe 2021
DOI: 10.1097/EE9.0000000000000183
Kamp e al. • En i onmen al Epidemiology (2021) 6:e183 www.en i onmen alepidemiology.com
3
Wi hin Equal-Li e, we dis inguish be ween he ex e nal expo-
some, subdi ided in o he physical exposome (e.g. aspec s o
he buil en i onmen , en i onmen al quali y indoo s and ou -
doo s), and he social exposome (e.g. socie al con ex , socio-
economic, social, and psychosocial ac o s a he indi idual and
he communi y le el), and he in e nal exposome. In e media e
e ec ma ke s o men al heal h include all he p ocesses, mea-
su able h ough me abolomics, epigenomics, p o eomics, and
gene exp ession, and measu es such as neu oimaging, neu o
-physiological and - psychological es s, ha happen in he body
a e exposu e.
The o e a ching aim o he Equal-Li e p ojec is o de elop
e idence-based guidance o policymake s, pa icula ly hose in
local go e nmen s and he child and you h (ca e) sec o . The
guidance will be used by hem in he iden i ica ion and design o
in e en ion s a egies, and p e en a i e measu es ocused on he
isk ac o s o men al heal h and he cogni i e- and socio-emo-
ional de elopmen o child en. E idence-based en i onmen al
heal h policy esponses (e.g. in planning, housing, anspo ,
schooling, egula ion, and p e en ion s a egies) can manage
ad e se en i onmen s and c ea e es o a i e ones; imp o ing
men al heal h and educing he o e all bu den o disease.
To achie e his aim, Equal-Li e pu sues ou objec i es as
ollows:
Objec i e #1: Equal-Li e seeks o inno a e in e nal and ex e -
nal exposu e assessmen . The app oach will combine aspec s o
ea ly-li e physical en i onmen s wi h social aspec s o he en i-
onmen . De elopmen al en i onmen s o child en and adoles-
cen s/young adul s a e he poin o a en ion because hey ha e
sys ema ically been unde s udied in his domain. Resilience o
exposu es la e and sel - egula ion capabili ies a e impo an
media o s.
Objec i e #2: De ine and map he pa hogenic and salu o-
genic en i onmen al ac o s o men al heal h and cogni i e
de elopmen
(1) by mapping he en i onmen al ea u es which a e ele-
an o es o a ion;
(2) by desc ibing and analyzing he associa ion be ween he
exposome and men al heal h a di e en de elopmen al
s ages;
(3) by s udying ea ly ma ke s o poo e men al and cogni-
i e de elopmen while accoun ing o en i onmen al
sensi i i ies.
Objec i e #3: Compose and explo e a se o in e en ions
o di e en li e-s ages wi h he pu pose o enhance he quali y
o se ings and spaces ele an o child en’s ac i i ies in hei
social con ex , leading o mo e heal h equi y.
Objec i e #4: De elop e idence-based guidance ha an ici-
pa es ajec o ies o changes in heal h dis ibu ion i he expo-
some, o i s elemen s, a e al e ed a di e en le els. The guidance
will be in such a o m as o inclusion o new in o ma ion can
be easily added o di e en pu poses (policy, esea ch, o in e -
en ion s udies).
Who is in he s udy?
Equal-li e makes use o exis ing da a om coho and school
s udies and will collec new da a (1) o en ich he exposu e da a
in he coho s (2) o mo e p ecisely ocus on and desc ibe ele-
an exposu es (3) o be e cha ac e ize he social and socie al
con ex , and (4) o p o ide u he in o ma ion ega ding ce -
ain child en’s men al heal h and cogni ion ou comes.
The coho s and school s udies
Equal-Li e has access o eigh Eu opean coho s, one na ional
longi udinal school s udy, and wo c oss-sec ional s udies.
Table 1 shows he included coho s and school s udies and
he di e en age g oups co e ed a baseline and ollow-up.
The geog aphy co e ed is p ima ily Wes e n Eu ope (se en
coun ies). The bi h coho s include a leas 226,807 child en
(mo he /child pai s) o whom longi udinal da a a e a ailable o
men al heal h and cogni i e de elopmen endpoin s, including
bioma ke s and epigene ics, and ela ed exposu es. The o he
s udies include an addi ional 15,866 child en, some o which
also p o ide pa en al in o ma ion and e ospec i e in o ma-
ion on pe ina al ci cums ances.
In o al, da a a e a ailable o 242,673 child en om p econ-
cep ion o 21 yea s. Mos da a a e collec ed a a egional, and
h ee a na ional (Finland, he Ne he lands, and Ge many) scale
as p esen ed in Figu e1.
Wha has and will be measu ed
The coho s and school s udies we e selec ed, based on hei
ocus on child en and da a a ailabili y on indica o s o men al
heal h and/o cogni i e de elopmen and on in o ma ion on he
key mechanism s udied (including s ess, sleep, sel - egula ion,
and es o a ion). Table2 p o ides an o e iew o he main con-
cep s ela ed o ou comes and media ing p ocesses.
The coho s and school s udies also include da a a di e en
loca ions and imes on a ange o exposu es, including aspec s o
he buil en i onmen , ou doo and indoo en i onmen al qual-
i y, and li es yle- ela ed ac o s. The coho and school s udies
a ailable wi hin Equal-Li e also comp ise da a on sociodemo-
g aphic cha ac e is ics and socioeconomic ci cums ances a he
indi idual le el o he child en. These da a a e cu en ly being
g ouped and desc ibed in de ail in an o e all ma ix o exposu e
da a o he coho s. Table3 p esen s a p elimina y o e iew o
wha is a ailable.
These exis ing da a will be en iched a he exposu e side, as
desc ibed below.
Table 1.
O e iew o he coho s and school s udies included in Equal-Li e p ojec .
Coho name Coho ype S udy design Geog aphical scale Coun y Age ange (yea s) Calenda yea Numbe o child en
PIAMA Bi h Longi udinal Na ional Ne he lands P ena al–20 1997–2018 4 000
FAIR Bi h Longi udinal Regional Sweden P ena al–12 2007–2018 200 000
ABCD Bi h Longi udinal Regional Ne he lands P ena al–14 2003–2018 8 266
WALNUTS Child/adolescence, School C oss-sec ional Regional Spain 11–14 2016–2018 700
BREATHE Child, school Longi udinal Regional Spain 7–11 2012–2013 2 878
FINNTWIN12 Twin- amily Longi udinal Na ional Finland 11–24 1994–2006 5 600
ALPINE Bi h (Re ospec i e) C oss-sec ional Regional Aus ia and I aly (p ena al) 8–11 2004–2005 1 251
ALSPAC Bi h Longi udinal Regional U.K. P ena al–11 1991–2008 14 541
RANCH Child, School C oss-sec ional Regional Ne he lands 9–10 2002 737 NL
NORAH Child, School C oss-sec ional Na ional Ge many 8 2012 1 243
STARS Adolescence C oss-sec ional Regional Sweden 13 2015–2019 2 283
Kamp e al. • En i onmen al Epidemiology (2021) 6:e183 En i onmen al Epidemiology
4
Ex e nal exposome and exposu e en ichmen
We aim o en ich he da a p o ided in Table3 wi h addi ional
exposu e da a on he ollowing en i onmen al physical and
social ac o s:
(1) he buil en i onmen 30 in u banized and u al a eas, includ-
ing housing quali y, age o building, le el o u baniza ion,
c owding, ype o neighbo hood, physical sa e y, access o
ameni ies such as playg ound, spo s g ound, pa ks, cul-
u e, and ele an mode a o s such as leng h o esidency;
(2) ou doo en i onmen al quali y including ai pollu ion, noise,
and sound g een and blue space, landscape, empe a u e,
ligh a nigh , and elec omagne ic ields, among o he s.
(3) indoo en i onmen al quali y, including d inking wa e
quali y, ligh a nigh and blue ligh , iew om he house,
dampness, ai quali y, sound and noise, dus , dampness and
molds, among o he s;
(4) socioeconomic cha ac e is ics o he neighbo hood o a a
mac o le el (e.g. dep i a ion and wel a e s a e policies)
The da a en ichmen will conside he ollowing ac o s:
(1) child en’s ac i i y pa e ns and hei loca ions (home, day-
ca e and (p e) school en i onmen , du ing commu ing/ ec-
ea ion), and ac oss di e en de elopmen al phases;
(2) he social en i onmen (e.g. mino i y s ess in ace o dis-
c imina ion, a achmen , pa en ing s yle, lone pa en ing,
social sa e y, social cohesion, social ne wo ks);
(3) li es yle (nu i ion, speci ic oods, suga in ake, physical
ac i i y and sc een ime, gaming and social media use).
The key mechanisms be ween exposu e and men al heal h (b ain
de elopmen , sleep, s ess/ es o a ion, and sel - egula ion) a e
highly ela ed o he buil and social en i onmen . They can be
conside ed as indi ec , media ing p ocesses in exposu e-ou -
come- ela ionships, o as di ec , biological e ec s ela ed o ai
quali y, noise, c owding, and ligh .16,31,32 The indi ec mecha-
nisms illus a e he necessi y o adop a dimensional app oach
o men al heal h and cogni i e de elopmen , complemen ing
he ca ego ical app oach o inal, clinical “endpoin s”. Apa
om acing hese indi ec mechanisms, we seek o elabo a e
on he biological a e ma h o hese as well. In u he de in-
ing he physical and social exposome, Equal-Li e akes men al
heal h and cogni i e de elopmen as a poin o depa u e. By
de ining men al heal h-enhancing en i onmen s a di e en li e
s ages and ime-ac i i y pa e ns in child en and adolescen s he
exposome is de eloped in a sys ema ic manne . The esul ing se
o indica o s (and c ea ed exposome) will be joined wi h new
(mic o) da ase s, om c owd-sou cing and social-media pla -
o ms, o spa ial da a on he en i onmen . The aim is o p o ide
quali a i e and quan i a i e insigh in o how child en and ado-
lescen s in e ac wi h he social and physical en i onmen s and
he men al heal h consequences.
In e nal exposome
E ec ma ke s o men al heal h will be explo ed on a selec ion
o child en, o which biological (mainly blood-de i ed plasma)
samples a e a ailable. The selec ion is based on high, medium,
and low sco es on he o al S eng h and Di icul y Index as a
p oxy o an o e all measu e o men al heal h, also known as
he p- ac o .33,34 Me abolic al e a ions such as changes in lip-
ids, a y acids, and abundan me aboli es a e epo ed o occu
du ing neu opsychia ic condi ions. In Equal-Li e, we will i s
measu e signa u es o he in e nal p ocesses linked o me abo-
lism, in lamma ion, and oxida i e s ess. This will be achie ed
by measu ing mi ochond ial, p o ein-based, and me abolo-
mics-based al e a ions in biological luids and compa ing he
esul s om heal hy child en o hose child en wi h a high isk o
men al dys unc ion. Second, he al e ed signa u es will be linked
o he ex e nal exposome analysis o heal h e ec s. This p ocess
Figu e 1. Geog aphical ep esen a ion o he coho and school s udies.
Kamp e al. • En i onmen al Epidemiology (2021) 6:e183 www.en i onmen alepidemiology.com
5
migh be epea ed o cogni i e e ec s as well, such as language
acquisi ion, a en ion, memo y, and IQ, oge he desc ibing luid
in elligence o he so-called g- ac o .35 An imp o ed unde s and-
ing o ma ke s o men al heal h and cogni i e de elopmen and
he ela ionship o hese bioma ke s o ex e nal exposu es a e
equi ed o ad ance men al heal h and cogni i e de elopmen
esea ch.
In dep h s udies
Wi hin he Equal-Li e p ojec , we aim o assess he e ec o
he o al en i onmen on men al heal h and cogni i e de elop-
men . The e ec ype o size may a y be ween ages and social
g oups. The e o e, he i s s ep in his p ocess is o in es i-
ga e wha en i onmen s child en o di e en ages, gende , and
social g oups isi , how o en hey go he e and how much ime
is spen a hese places. Table4 p o ides an o e iew o he
loca ion, objec i e and, design o he in-dep h s udies. These
in-dep h s udies a e expe imen al s udies o collec addi ional
da a on he e ec o he o al en i onmen on men al heal h and
cogni i e de elopmen .
Me hod
The i s s eps o he p ojec ocus on de ining key concep s and
ques ions ela ed o men al heal h and cogni i e de elopmen ,
while desc ibing speci ic needs and ulne abili ies ela ed o age.
These include he po en ial in luence o he exposome, ela ed
mechanisms as well as ac i i y spaces and pa e ns ele an and
cha ac e is ic o child en.
The ques ions o be answe ed by Equal-Li e will be discussed
wi h a b oad ange o s akeholde s a an ea ly s age o ensu e
ha he in o ma ion needs o all ele an s akeholde s (e.g. pol-
icymake s) a e add essed.
Table 5 shows he se en s eps o he me hod applied in
Equal-Li e. These s eps a e explained in Table5 and a e linked
o objec i es, ac i i ies, and indings o da e and da a sou ces.
Based on he ac i i ies, asks, and deli e ables in ea lie s ages
o he p ojec , a se o esea ch ques ions and speci ic hypo heses
is cu en ly unde de elopmen . This is a s ill ongoing p ocess.
Figu e2 shows he di e en in o ma ion sou ces used o de i -
ing esea ch ques ions, which a e also desc ibed in Table5.
Mechanisms and li e-cou se o m he key elemen s o ou
hypo hesis-d i en app oach. Building on exis ing heo ies and
knowledge on neu obiological and -psychological de elopmen
o child en and adolescen s i.e36–38 he li e a u e was e iewed o
ex end ou knowledge on how exposome could a ec de elopmen
and men al heal h. Th ee mechanisms we e explo ed in pa icula :
psychosocial and psychophysiological s ess, sel - egula ion/cop-
ing, and sleep quali y. The assump ion is ha hese mechanisms
could media e he linkage be ween exposome and child neu ode-
elopmen and hus a ec men al heal h and cogni i e unc ion.
The second impo an aspec in ou app oach is a li e-cou se
pe spec i e o he ull linkage o he exposome, media o s, and
ou comes. Exis ing li e-cou se epidemiological models 39,40 a e
being s udied, s essing he accumula ion o haza ds/ isks o e
he yea s and he in luence his migh ha e a ce ain ages, ei he
indi ec ly ia media o s o di ec ly on he ou comes a o he
ages. No only isks bu also suppo i e en i onmen s a di e -
en ages will be conside ed.
S eng hs and limi a ions
S eng hs
(1) Equal-Li e ea u es a holis ic app oach o child en i on-
men s and pe o ms he ull alue chain om he de el-
opmen o he exposome, ia heal h assessmen o de elop
a se o in e en ions. A he same ime, he b oadness o
he exposome is ci cumsc ibed as he p ojec akes men-
al heal h and cogni i e de elopmen as a s a ing poin .
The Equal-Li e app oach is no el in: he combina ion o
physical and social elemen s o he exposome; he sex/gen-
de -sensi i e concep ualiza ion wi h an in e sec ionali y
pe spec i e o he exposome as a empo ally and spa ially
dynamic and mul idimensional p ocess; and he ocus on
men al heal h and cogni i e de elopmen . Exposome p oj-
ec s hus a ha e been p ima ily ocused on soma ic dis-
ease and did no ake dimensions o en i onmen al jus ice
and heal h equi y in o accoun .
(2) The p ojec will explo e new bioma ke s o men al
heal h. These a e in e media e e ec ma ke s, which will
Table 2.
Key concep s (ou comes and media o s).
OUTCOMES
DOMAIN: MENTAL HEALTH
Men al ill-heal h o illness
Psychological o psychia ic illness o psychological ill-heal h (psychopa hology)
Well-being, o posi i e men al heal h
“a s a e o well-being in which e e y indi idual ealizes his o he own po en ial, can
cope wi h he no mal s esses o li e, can wo k p oduc i ely and ui ully, and is able
o make a con ibu ion o he o his communi y”41
The gene al ac o o psychopa hology ( he p- ac o )33
DOMAIN: COGNITION
Gene al Cogni i e Func ions
P ocessing speed (simple eac ion ime, speeded c ossing-ou - asks, speeded isual
ma ching asks)
Basic execu i e unc ions
• Inhibi o y con ol (e.g., lanke ask, s oop ask, go-nogo ask, s opsignal ask,
and lanke ask)
• Cogni i e lexibili y (swi ching asks, e.g, dimensional ca d so ing, and numbe -
le e ask)
• Wo king memo y (e.g., n-back ask, digi span backwa ds, unning memo y,
and ope a ion span)
Highe -le el execu i e unc ions
• Reasoning ( luid in elligence, e.g., Ra en´s Ma ices, Cul u e-Fai Tes , SON-R)
• Planning and p oblem-sol ing (e.g., Towe s o Hanoi, Maze Tes )
Language Acquisi ion
O al language unc ions (phonology, ocabula y, G amma , Lis ening Comp ehension)
W i en language unc ions
• P ecu so s o li e acy (e.g., phonological awa eness, apid naming)
• Basic li e acy unc ions (decoding skills, e.g., eading and spelling eal wo ds
and pseudowo ds)
• Reading comp ehension and luency
• Clinical diagnosis o de elopmen al dyslexia
School Achie emen /Academic Achie emen
G ades, School-lea ing quali ica ion, Educa ional Le el quali ica ion, Educa ional Le el
MEDIATORS
DOMAIN: COPING/SELF-REGULATION
Sel - egula ion: ela ed e ms (e.g., emo ion egula ion), de e minan s, long- e m
ou comes, measu es (e.g., Ma shmellow- es , pa en ques ionnai es)
Coping and coping s yles (e.g., engagemen s. disengagemen )
DOMAIN: SLEEP
Measu es o sleep quan i y and sleep pa e n
Measu es o sleep quali y
Sleep ela ed ou comes (sho e m)
Sleep ela ed beha io
Time
DOMAIN: RESTORATION
Ac ual es o a ion
Pe cei ed es o a ion
Res o a i eness/ es o a i e quali y (pe cei ed and objec i e)
Ins o a ion
DOMAIN: STRESS
S ess as p ocess
Psychological s ess (pe cei ed s ess)
Psycho-physiological s ess ( esponses)

Kamp e al. • En i onmen al Epidemiology (2021) 6:e183 En i onmen al Epidemiology
6
Table 3.
O e iew o he da a on ex e nal exposome ca ego ies a ailable in he coho and school s udies be o e da a en ichmen .
S udy →PIAMA FAIR ABCD WALNUTS BREATHE FinnTwin12 ALPINE ALPAC RANCH NORAH STARS
Physical en i onmen
Noise X X X X X X Y X X
Ai pollu ion (ou doo ) X X X X X X X X
Ai pollu ion (indoo ) X X
ETS (smoking pa en s) X X X X X
G een space X X X X X X
Molds and dampness X X X
Type o house X X X X
Vib a ion X X
Elec omagne ic ields X X
Li e s yle ac o s
Nu i ion/ea ing beha io X X X X X X X
Physical ac i i yaX X X X X X X X X
(Mo he ’s) BMI/an h opome ics X X X X X
Mo he ’s alcohol use X X X X
Mo he ’s ca eine use X X X
(Mo he ’s) d ug use X X X
TV/ adio consump ion X X X
Mobile phone and in e ne use X X X
Sc een use X X
Social en i onmen
Being bullied X X X X
C owding/densi y X X X X
(Pa en al) educa ion X X X X X X X X
(Pa en al) occupa ion X X X X X X X
Pa en al income X X X X X X
Na ionali y/e hnici y X X X X X X X
Pa en al ma i al s a us X X X X X
Social/pa en al suppo X X X X X
Neighbo hood SES X X Y X
Sa is ac ionbX X X X X
Social en i onmen c X X X X X
aphysical ac i i y indica o , including seden a y ac i i y.
bSa is ac ion wi h di e en aspec s o (social) li e.
cNo u he speci ied.
Table 4.
O e iew in-dep h s udies.
In-dep h s udy Objec i e S udy ype
Ac i i y pa e ns To in es iga e wha en i onmen s child en om di e en
social and age g oups, isi , how o en hey go and how
much ime hey spend he e.
Th ee-phase c oss-sec ional s udy is planned (N = 385) including a su ey, a ime-ac i i y-
exposu e pa e n pilo and alida ion by means o GPS, dia ies and pe sonal exposu es
Audi o y cogni ion in
ac i i y based acous ic
se ings
To examine he in luence o eal-li e class oom
scena ios on audi o y p ocessing and cogni i e
pe o mances. To iden i y key indica o s o class oom
acous ic scena io’s.
To e alua e sound ep oduc ion me hods sui able o
child en in lis ening expe imen s.
A se ies o 8–10 lis ening expe imen s is pe o med wi h wo pa adigms: (1) audi o y selec i e
a en ion and (2) speech in elligibili y. Fo each expe imen 30 child en (3–10 yea s) and 24
young adul s (18–26 yea s) a e ec ui ed ia educa ional ins i u ions and unde ad ice o he
educa o s and eache s.
P eschool s udy in
Ge many and Belgium
To s udy he e ec s o physical and social exposu es
a (p e-) school and a home on child en´s well-being,
cogni ion, and EEG pa ame e s o audi o y p ocessing.
The s udy design is longi udinal wi h wo measu emen wa es sepa a ed by a pe iod o 14
mon hs ( 1: p eschool, age 5; 2: p ima y school, age 7) a 2 s udy si es (Ge many and Belgium).
Noise exposu e and ai quali y will be assessed using senso de ices a bo h measu emen
wa es. En i onmen al quali y a home and a school as well as social indica o s will be
assessed by ques ionnai es o child en, eache s, and pa en s.
Sleep s udy in Sweden
and Aus ia
To inc ease ou unde s anding o how he exposome
a ec s men al heal h and cogni ion ia sleep.
Child en a e selec ed based on combined indica o s o noise and ai -pollu ion exposu e and
g een space. Sleep quali y and sleep pa e ns will be measu ed in he pa icipan s’ home using
ques ionnai es and objec i e sleep measu es making use o senso s. Exclusion c i e ia include
sleep apnea and skin i i a ion.
The Swedish sleep s udy comp ises child en (10–17 yea s) ec ui ed om he STARS coho .
The Aus ian sleep s udy comp ises child en (8–14 yea s) ec ui ed om a s udy among adul s
(N~1200).
be linked o exposu es e ospec i ely. These da a we e
a ailable, bu no ye explo ed and es ed in a la ge
g oup and linked o exposu es. The use o a la ge se o
coho s and school da a, all con aining compa able da a
on men al heal h and cogni i e de elopmen , will allow
o mo e de ailed analysis wi h enough s a is ical powe .
Kamp e al. • En i onmen al Epidemiology (2021) 6:e183 www.en i onmen alepidemiology.com
7
Table 5.
Se en s ep app oach.
S ep #
P ocess
s ep name Objec i e
In o ma ion and da a
sou ces
Ac i i ies and indings
up ill now
1 De ine To de ine pa hways om exposu e
indica o s owa ds ou comes
Li e a u e heo y The key concep o men al heal h, cogni i e de elopmen , he
mechanisms o sleep, sel - egula ion and s ess and es o a ion
and de ining he physical, social and in e nal exposome.
Fou scoping e iews a e being inalized on he key mechanisms
(s ess, sel - egula ion, and sleep) and he ole o he social exposome.
Exis ing coho and school s udy da a a e being g ouped along he key
dimensions add essed in Equal-Li e.
2 Consul and
Selec
To include inpu om ele an
s akeholde s a an ea ly s age in he
p ojec
Delphi consul a ion
Online ocus g oups
Dialogues
A Delphi consul a ion (wi h h ee ounds) among expe s and he
s akeholde s was de eloped and pe o med o ma ch he key scien i ic
and policy o ien ed ques ions o be add essed in Equal-Li e.
A code and p o ocol was de eloped o selec child en o bioma ke
analyses in blood plasma, based on he o al sco e on he S eng h and
Di icul y Ques ionnai e (SDQ) as indica o o he so-called p- ac o which
is conside ed as isk ac o o u u e men al heal h p oblems.
Two coho s we e selec ed o bioma ke analysis aimed a explo ing new
ma ke s o men al heal h.
The p ocess o da a and ma e ial ans e (xy coo dina es and plasma)
be ween he da a owne s and en iche s is nea ly comple ed.
3 Collec To collec da a wi hin he en i onmen s
de ined as ele an o men al heal h
and cogni i e de elopmen o child en
and adolescen
GIS based his o ic in o ma ion
Measu es
Senso s
In e ne o Things
Dia ies
A p o ocol was de eloped o he ans e o xy coo dina es and me ada a
o m he coho s and school s udies.
4 Ma ch To compose he exposome based on
h ee and ma ch wi h he key ou come
da a in he a ailable da a se s.
Bi h coho da a
School s udy da a
Re ospec i e longi udinal
5 Analyze To analyze he associa ion be ween
he ex e nal exposome and men al and
cogni i e e ec s.
Machine lea ning is used o explo e he ele an a iables in indi idual
coho o school s udies in a non- a ge ed and da a-d i en manne .
Random o es was chosen as me hod.
A code was de eloped o apply machine lea ning in he non a ge ed
phase o he s udy o iden i y ele an ea u es in he coho s and school
s udies. The ou pu can be used o explo e wha p edic o s a e impo an
o men al heal h, and se e as inpu o he concep ual model. The code
is s o ed on Gi Hub, making i easily accessible o all Equal- Li e pa ne s
and beyond.
6 T ansla e:
in e en ions and
ools
To in o m s akeholde s and
policymake s o he bes - and
p omising in e en ion analysis.
7 Communica e To communica e he ou comes o a
ange o audiences.
S eps dis ibu ed o e he di e en Wo k-Packages o Equal-Li e (WP) s ep 1: WP1 and 4; s ep 2: WP8; s ep 3: WP 1–5; s ep 4: WP7; s ep 5: WP2, 6 and 7; s ep 6: WP8, 9, 10; s ep 7: WP10, 11, All.
Figu e 2. Sou ces o in o ma ion used o de i ing esea ch ques ions.
Kamp e al. • En i onmen al Epidemiology (2021) 6:e183 En i onmen al Epidemiology
8
(3) Equal-Li e ea u es a conso ium o pa ne s ha includes
a b oad and complemen a y ange o disciplina y back-
g ounds necessa y o explo e he ull causal chain, om
exposu e o policy in e en ions and eedback.
(4) Fo he i s ime in he ield o he exposome, we in oduce
he concep o ocusing no only on isks and haza ds ha
child en un in hei daily en i onmen bu also on he pos-
i i e po en ial o he en i onmen on child wellbeing and
ecupe a ion om daily s esso s.
(5) Equal-li e will use no el mic oda a and en ich he expo-
some wi h “un apped” physical and social exposome
pa ame e s. The no el y o using new o ms o da a such
as use -gene a ed con en om social media, online map-
ping, s ee -le el image y, and c owdsou cing campaigns in
he s udy o en i onmen al exposu es p ima ily lies in he
en ichmen possibili ies ha hese da a o e . In pa icula ,
hey can cap u e aspec s o people’s daily li e and he phys-
ical en i onmen , such as human pe cep ions, expe iences,
and in e ac ions a la ge scales, as e idenced by nume ous
s udies in a ious scien i ic ields. The use o such da a in
exposu e s udies o da e has been limi ed. Equal-Li e aims
o ill his gap by le e aging he g anula i y o such da a
and by b inging hem in o he co e o he p oposed en ich-
men s a egy.
(6) Thus a many s udies in he ield o en i onmen and
heal h ha e been ocused on speci ic subg oups. Ou coho
da a include a b oad g oup o Eu opean (EU) child en and
in some coho s s a i ica ion on e hnici y, mig an back-
g ound o aspec s o accul u a ion, and o he demog aphic
ea u es is possible.
(7) To be able o adequa ely add ess heal h inequi ies, mul i-
le el analyses will be applied o dis inguish heal h e ec s o
social ac o s a he indi idual le el om hose o neighbo -
hood- o mac o-le el. Mo eo e , Equal-Li e will conduc
case s udies o assess equi y impac s o in e en ions o pol-
icies o di e en sec o s.
(8) Ou p oposed me hod o da a analyses i s explo es da a
in a non a ge ed way using machine lea ning and nex wi h
a a ge ed (hypo hesis d i en) app oach o ackle he com-
plexi y o he associa ions. This is a unique app oach as a
as men al heal h and cogni i e de elopmen a e conce ned.
(9) Including s akeholde s o e he p ojec li e ime is no inno-
a i e, bu in ol ing hem ac i ely in se ing he scene by
co o mula ing he ele an ques ions om a policy and
planning poin o iew, and codesigning u u e ools o
assess policy in e en ions, akes he exposome endea o
away om he labo a o ies and in o he ield ( eal li e, eal
people, eal ime and eal loca ions).
Equal-Li e will explo e he ways o sus ain (and main ain) hese
ools also a e he end o he p ojec . By linking hem as much
as possible o local ools hey will be mo e ailo ed o he needs
o di e en EU egions. The pa icipa ing public heal h ins i-
u es could suppo guidance ools wi h upda es wi hin hei
p og ams which a e inanced on a egula basis. In o he wo ds:
he ools will be ac i e ins ead o passi e aiming a op imal
exploi a ion.
Challenges and limi a ions
Equal-Li e aces se e al ex e nal ba ie s ha may h ea en
he achie emen o he desi ed impac om he p ojec . These
include low engagemen o s akeholde s, lack o da a a ailabil-
i y, low up ake o he oolki , and di icul ies o main ain and
upda e he oolki wi h new da a and in o ma ion. E en he
mos sophis ica ed s a is ical me hods canno sol e gaps caused
by issues o da a a ailabili y, compa abili y, and quali y.
S a is ical da a analyses need o ake he quali y o he a ail-
able da a in o accoun . Equal-Li e has access o high-quali y
da a, bu he ha moniza ion o he da a ac oss he coho s and
school s udies is one o he key challenges. A dual app oach,
combining an explo a i e and a mo e analy ical app oach is
seen as he mos ealis ic way o mo e o wa d. In he analy ic
app oach, s a e-o - he-a me hods o analyzing causali ies,
such as p opensi y sco e me hods among o he s and media ion
analyses a e conside ed.
The p ojec has many in e dependencies be ween wo k
packages including many pa ne s om a di e se se o dis-
ciplina y backg ounds. This poses a challenge o Equal-Li e
as well.
Equal-Li e will also ace complica ed da a managemen issues
and when main enance a e he p ojec inishes, and we ace he
challenge o ying o gene alize he ou comes o all Eu opean
coun ies, whe eas many coun ies a e no co e ed by he da a.
Finally, he cu en ly ongoing COVID-19 pandemic will com-
plica e he execu ion o s udies ha in ol e immedia e con ac
wi h child en.
Conclusion
Men al heal h is he esul o he complex in e play be ween
gene ic, psychological, physical and social en i onmen , and
o he ac o s and expe iences. The li e-cou se exposome con-
cep , e e ing o he o ali y o exposu es om concep ion
onwa ds, is eme ging as a e y p omising app oach in s udying
he ole o he en i onmen in human disease. The EU- unded
Equal-Li e p ojec will de elop and u ilize he exposome con-
cep in an in eg a ed s udy o he ex e nal exposome and o
measu able in e nal biological ac o s and link hose o a child’s
de elopmen and li e cou se men al heal h. This will be ca ied
ou using a no el app oach combining exposu e da a o cha ac-
e ize, measu e, model, and unde s and in luences and inequi ies
a di e en de elopmen al s ages. The goal is o p opose he bes
suppo i e en i onmen s o all child en.
Collabo a ion
The Equal-Li e conso ium consis s o 22 pa ne s, 2 subcon-
ac o s, 4 in e na ional ad iso s, and 1 s akeholde chai ing he
ad iso y eam.
The conso ium b ings oge he a ious ypes o ins i u ions
including go e nmen al ins i u es, uni e si ies, and esea ch
Small and Medium En e p ises. Equal-Li e combines ex ensi e
mul idisciplina y expe ise om leading expe s in he ields
anging om public heal h, epidemiology, child psychology,
mic obiology, en i onmen al psychology, a chi ec u e, en i-
onmen al-, and spa ial planning, neu obiology, geog aphic,
poli ical sciences, physics, in o ma ion and communica ions
echnology, o s a is ical modeling. These expe s b ing knowl-
edge on en i onmen and heal h in child en om hei own
coun y, and om hei b oade in e na ional ne wo ks. Equal-
Li e’s po en ial end-use s comp ise local au ho i ies, NGOs such
as he WHO Eu opean Heal hy Ci y Ne wo k, u ban planne s,
and o he s.
Equal-Li e is a membe o he Eu opean Human Exposome
Ne wo k which b ings oge he nine esea ch p ojec s, ecei -
ing o e €100 million om Ho izon 2020, he EU’s amewo k
p og am o esea ch and inno a ion. These p ojec s add ess
issues such as exposu es o ai quali y, noise, chemicals, u ban-
iza ion, and heal h impac s. The p ojec s’ esul s will con ibu e
o ad ancing he Eu opean G een Deal’s ambi ion o p o ec ci -
izens’ heal h and well-being om pollu ion and en i onmen al
de e io a ion by p o iding new e idence o be e p e en i e
policies.
Acknowledgmen s
The au ho s g a e ully acknowledge he con ibu ion o all
Equal-Li e conso ium membe s and he membe s o he
ad iso y commi ee (www.equal-li e.eu). Au ho s also hank
Kamp e al. • En i onmen al Epidemiology (2021) 6:e183 www.en i onmen alepidemiology.com
9
Yun Cheng and Pe e F ibe g om Go henbu g Uni e si y
o making he da a om he STARS coho a ailable. This
p ojec has ecei ed unding om he Eu opean Union’s
Ho izon 2020 esea ch and inno a ion p og am unde g an
ag eemen No 874724 and is co- unded by he In e na ional
S a egic Resea ch Scheme o he Na ional Ins i u e o Public
Heal h and he En i onmen in he Ne he lands and by he
Du ch Minis y o In as uc u e and Wa e Managemen
Di ec o a e Sus ainable Li ing En i onmen and Ci cula
Economy.
APPENDIX
The membe s o Equal-Li e Scien i ic Team a e as ollows: Agnes
Wibe g, School o Public Heal h and Communi y Medicine,
Go henbu g Uni e si y, Go henbu g, Sweden; Albe Amb òs,
Ba celona Ins i u e o Global Heal h, ISGlobal, Ba celona,
Spain; Albe Wong, Cen e o Nu i ion, P e en ion and
Heal h Se ices, Na ional Ins i u e o Public Heal h and
he En i onmen , Bil ho en, The Ne he lands; Alyce Whipp,
Ins i u e o Molecula Medicine Finland, Depa men o
Public Heal h Uni e si y o Helsinki, Helsinki, Finland;
And ei Pyko, Uni o Occupa ional Medicine a he Ins i u e
o En i onmen al Medicine, Ka olinska Ins i u e , S ockholm,
Sweden; Angel Dzhambo , Ins i u e o Highway Enginee ing
and T anspo Planning, G az Uni e si y o Technology, G az,
Aus ia; Anna Hansell, Cen e o En i onmen al Heal h
and Sus ainabili y & School o Geog aphy, Geology and
he En i onmen , Uni e si y o Leices e , Leices e , Uni ed
Kingdom; Anna Sandionigi, Quan ia Consul ing s l, Milan,
I aly; Anneke Bloks a, Cen e o Nu i ion, P e en ion and
Heal h Se ices, Na ional Ins i u e o Public Heal h and he
En i onmen , Bil ho en, The Ne he lands; An onia Valen in,
Ba celona Ins i u e o Global Heal h, ISGlobal, Ba celona,
Spain; A o Ala alo, A.I.Vi anen Ins i u e o Molecula
Sciences, Uni e si y o Eas e n Finland, Kuopio, Finland;
A zu A a , Uni o Occupa ional Medicine a he Ins i u e o
En i onmen al Medicine, Ka olinska Ins i u e , S ockholm,
Sweden; Ba ba a Mihe c, Na ional Ins i u e o Public Heal h,
Ljubljana, Slo enia; B uno Raimbaul , Ba celona Ins i u e o
Global Heal h, ISGlobal, Ba celona, Spain; Cal in Jephco e,
Cen e o En i onmen al Heal h and Sus ainabili y & School
o Geog aphy, Geology and he En i onmen , Uni e si y o
Leices e , Leices e , Uni ed Kingdom; Cha lo a E iksson, Uni
o Occupa ional Medicine a he Ins i u e o En i onmen al
Medicine, Ka olinska Ins i u e , S ockholm, Sweden; Ch is in
Belke, Cen e o Applied Psychology, En i onmen al and Social
Resea ch (Zeus GmbH ), Bochum, Ge many; Ch is oph Giehl,
Depa men o Cogni i e and De elopmen al Psychology,
Technical Uni e si y Kaise slau e n, Kaise slau e n, Ge many;
Elise an Kempen, Cen e o Sus ainabili y, En i onmen
and Heal h, Na ional Ins i u e o Public Heal h and he
En i onmen , Bil ho en, The Ne he lands; Ge d Ko uem,
Join Resea ch Cen e o U ban Sys ems and En i onmen ,
Del Uni e si y o Technology, Del , The Ne he lands;
Helena Sk öde , Uni o Occupa ional Medicine a he Ins i u e
o En i onmen al Medicine, Ka olinska Ins i u e , S ockholm,
Sweden; Igo Spi oski, Ins i u e o Public Heal h o he Republic
o No h Macedonia, Skopje, No h Macedonia; Izaque de
Sousa Maciel, A.I.Vi anen Ins i u e o Molecula Sciences,
Uni e si y o Eas e n Finland, Kuopio, Finland; Jan Spilski,
Depa men o Cogni i e and De elopmen al Psychology,
Technical Uni e si y Kaise slau e n, Kaise slau e n, Ge many;
Jana Roczen, Ins i u e o Public Heal h and Nu sing Resea ch,
Uni e si y o B emen, B emen, Ge many; Jespe Lö e, School
o Public Heal h and Communi y Medicine, Go henbu g
Uni e si y, Go henbu g, Sweden; John Bol e, Cen e o
Sus ainabili y, En i onmen and Heal h, Na ional Ins i u e
o Public Heal h and he En i onmen , Bil ho en, The
Ne he lands; Jolanda Boe , Cen e o Nu i ion, P e en ion
and Heal h Se ices, Na ional Ins i u e o Public Heal h and
he En i onmen , Bil ho en, The Ne he lands; Ka in Loh,
Hea ing Technology and Acous ics, RWTH Aachen Uni e si y,
Aachen, Ge many; Ka h yn Adams, Cen e o En i onmen al
Heal h and Sus ainabili y & School o Geog aphy, Geology
and he En i onmen , Uni e si y o Leices e , Leices e , Uni ed
Kingdom; Kim Whi e, Cen e o Sus ainabili y, En i onmen
and Heal h, Na ional Ins i u e o Public Heal h and he
En i onmen , Bil ho en, The Ne he lands; La issa Leis ,
Depa men o Cogni i e and De elopmen al Psychology,
Technical Uni e si y Kaise slau e n, Kaise slau e n, Ge many;
Lena Gudi-Minde mann, Ins i u e o Public Heal h and
Nu sing Resea ch, Uni e si y o B emen, B emen, Ge many;
Luc Dekoninck, Depa men o In o ma ion echnology,
Facul y o Enginee ing and A chi ec u e, Ghen Uni e si y,
Ghen , Belgium; Maddie Whi e, Ins i u e o Public Heal h and
Nu sing Resea ch, Uni e si y o B emen, B emen, Ge many;
Ma Ál a ez-Ped e ol, Ba celona Ins i u e o Global Heal h,
ISGlobal, Ba celona, Spain; Ma co Balduini, Quan ia
Consul ing s l, Milan, I aly; Ma ja Heinonen-Guzeje , Ins i u e
o Molecula Medicine Finland, Depa men o Public Heal h
Uni e si y o Helsinki, Helsinki, Finland; Maud Dohmen, Buil
En i onmen , Technical Uni e si y Eindho en, Eindho en,
The Ne he lands; Michael Smi h, School o Public Heal h and
Communi y Medicine, Go henbu g Uni e si y, Go henbu g,
Sweden; Michail E angelos Te zakis, Buil En i onmen ,
Technical Uni e si y Eindho en, Eindho en, The Ne he lands;
Mihail Kochubo ski, Ins i u e o Public Heal h o he Republic
o No h Macedonia, Skopje, No h Macedonia; Na alia
Vincens, School o Public Heal h and Communi y Medicine,
Go henbu g Uni e si y, Go henbu g, Sweden; Na aša F igelj,
Na ional Ins i u e o Public Heal h, Ljubljana, Slo enia; Rik
Boge s, Cen e o Sus ainabili y, En i onmen and Heal h,
Na ional Ins i u e o Public Heal h and he En i onmen ,
Bil ho en, The Ne he lands; Roos Teeuwen, Join Resea ch
Cen e o U ban Sys ems and En i onmen , Del Uni e si y
o Technology, Del , The Ne he lands; Sammie Jansen, Cen e
o Sus ainabili y, En i onmen and Heal h, Na ional Ins i u e
o Public Heal h and he En i onmen , Bil ho en, The
Ne he lands; Sa ah Leona Benz, Cen e o Applied Psychology,
En i onmen al and Social Resea ch (Zeus GmbH), Bochum,
Ge many; Sa ah Ve huls , Depa men o In o ma ion echnol-
ogy, Facul y o Enginee ing and A chi ec u e, Ghen Uni e si y,
Ghen , Belgium; Shaban Meme i, Ins i u e o Public heal h o
he Republic o No h Macedonia, Skopje, No h Macedonia;
Ta iana Al a es-Sanches, Cen e o En i onmen al Heal h
and Sus ainabili y & School o Geog aphy, Geology and
he En i onmen , Uni e si y o Leices e , Leices e , Uni ed
Kingdom; Thomas Lachmann, Depa men o Cogni i e
and De elopmen al Psychology, Technical Uni e si y
Kaise slau e n, Kaise slau e n, Ge many; Timo hy Van
Ren e ghem, Depa men o In o ma ion echnology, Facul y
o Enginee ing and A chi ec u e, Ghen Uni e si y, Ghen ,
Belgium; Vasileios Milias, Join Resea ch Cen e o U ban
Sys ems and En i onmen , Del Uni e si y o Technology,
Del , The Ne he lands; Wim Swa , Cen e o Sus ainabili y,
En i onmen and Heal h, Na ional Ins i u e o Public Heal h
and he En i onmen , Bil ho en, The Ne he lands.
Re e ences
1. OECD/EU. Heal h a a glance: Eu ope 2016: s a e o heal h in he EU
cycle. OECD, 2016.
2. Fe guson KT, Cassells RC, MacAllis e JW, E ans GW. The physical
en i onmen and child de elopmen : an in e na ional e iew. In J
Psychol. 2013;48:437–468.
3. E ans GW, Ma cynyszyn LA. En i onmen al jus ice, cumula i e en i-
onmen al isk, and heal h among low- and middle-income child en in
ups a e New Yo k. Am J Public Heal h. 2004;94:1942–1944.
4. Helbich M. F on ie s in Men al Heal h and he En i onmen MDPI-
Mul idisciplina y Digi al Publishing Ins i u e; 2018.