Cumulative exposure to chemical and non-chemical stressors combine to influence susceptibility to health effects. Currently, the most common way to address exposure to non-chemical stressors in the context of cumulative impact assessment (CIA) is using screening tools. While screening tools can generally identify communities that have the potential for disproportionately higher exposure to chemical and non-chemical stressors,  screening tools do not quantitatively assess the contribution of the interaction among chemical and non-chemical stressors to cumulative health impacts.  As part of a comprehensive review of CIA methods, a reoccurring recommendation was that multi-stakeholder collaboration using visualization tools in conjunction with epidemiological information could be used to account for and communicate causal relationships between non-chemical stressors, chemical stressors, and cumulative health impacts.

Our work involved a structured literature search that identified currently available information and methods for addressing the interaction of non-chemical and chemical stressors in CIA. A total of 74 articles were reviewed that used observational epidemiology to address potential associations between health effects and various other factors typically associated with vulnerable communities. The role of observational epidemiology encompassed in these studies is summarized along with opportunities, challenges, and limitations to using epidemiology for incorporating non-chemical and chemical stressor interactions into a CIA. In addition, available visualization tools are summarized in the context of their use in conjunction with epidemiological information for facilitating multi-stakeholder and multi-discipline planning and agreement on key associations among chemical and non-chemical stressors and cumulative health impacts, strength of associations, and quality of underlying evidence. This can improve the design of the CIA, the effectiveness of interventions, and acceptance of decisions based on the CIA findings