Heat index in migrant farmworker housing: implications for rest and recovery from work-related heat stress

Although the health risk to farmworkers of working in hot conditions is recognized, potential for excessive heat exposure in housing affecting rest and recovery has been ignored. We assessed heat index in common and sleeping rooms in 170 North Carolina farmworker camps across a summer and examined associations with time of summer and air conditioning use. We recorded dangerous heat indexes in most rooms, regardless of time or air conditioning. Policies to reduce heat indexes in farmworker housing should be developed.

Traditional and commercial herb use in health self- management among rural multiethnic older adults

This study analyzes the role of traditional and commercial herbs in older adults’ health self-management based on Leventhal’s Self-Regulatory Model conceptual framework. Sixty-two African American and White adults age 65 and older completed qualitative interviews describing the forms of herbs currently being used, sources of information about them, interpretations of health (acute symptoms or chronic conditions) that led to their use, and the initiation and suspension of use. Traditional herbs are native to the region or have been traditionally cultivated, usually taken raw or boiled to produce tea, and used for treating mild symptoms. Commercial herbs are prepared as pills, extracts, or teas; they are purchased at local stores or ordered by catalog or Internet and used for health promotion, illness prevention, or treatment of chronic conditions. Herbs are widely used among older adults; this analysis differentiates the types of herbs they use and their reasons for herbs use.

Translating the Dietary Approaches to Stop Hypertension (DASH) diet for use in underresourced, urban African American communities, 2010

Introduction

Randomized trials have demonstrated the effectiveness of the Dietary Approaches to Stop Hypertension (DASH) program for lowering blood pressure; however, program participation has been limited in some populations. The objective of this pilot study was to test the feasibility of using a culturally modified version of DASH among African Americans in an underresourced community.

Methods

This randomized controlled pilot study recruited African Americans in 2 North Carolina neighborhoods who had high blood pressure and used fewer than 3 antihypertension medications. We offered 2 individual and 9 group DASH sessions to intervention participants and 1 individual session and printed DASH educational materials to control participants. We collected data at baseline (March 2010) and 12 weeks (June 2010).

Results

Of 152 potential participants, 25 were randomly assigned to either the intervention (n = 14) or the control (n = 11) group; 22 were women, and 21 were educated beyond high school. At baseline, mean blood pressure was 130/78 mm Hg; 19 participants used antihypertension medications, and mean body mass index was 35.9 kg/m². Intervention participants attended 7 of 9 group sessions on average. After 12 weeks, we observed significant increases in fruit and vegetable consumption and increases in participants’ confidence in their ability to reduce salt and fat consumption and eat healthier snacks in intervention compared with control participants. We found no significant decreases in blood pressure.

Conclusion

Implementation of a culturally modified, community-based DASH intervention was feasible in our small sample of African Americans, which included people being treated for high blood pressure. Future studies should evaluate the long-term effect of this program in a larger sample.

The association of skin conditions with housing conditions among North Carolina Latino migrant farm workers

BACKGROUND

Skin conditions are common among Latino migrant farm workers. Although many skin conditions are related to occupational exposures, poor housing conditions may also contribute to skin ailments in migrant farm workers.

OBJECTIVES

To evaluate the association between housing conditions and skin conditions among Latino migrant farm workers.

MATERIALS AND METHODS

A cross-sectional study design using interview questionnaires, home inspections, and environmental sampling was implemented to document housing quality of farm worker camps/homes and the prevalence of self-reported skin conditions in Latino migrant farm workers. Interviews were completed with 371 farm workers residing in 186 of the 226 camps (camp response rate 82.3%).

RESULTS

Self-reported pruritus (31%), rash (25%), scaling (12%), blisters (11%), and ingrown nails (10%) were common among the participants. Pruritus was more likely to be reported by farm workers living in dwellings without air-conditioning (P < 0.05). Rash was associated with dwellings reported to have a low humidity (P < 0.05). Scaling was more likely to be reported by farm workers living in dwellings with indoor temperatures in the thermal discomfort range (P < 0.05). No statistically significant associations were detected for indoor allergens and self-reported skin ailments among migrant farm workers.

CONCLUSIONS

Skin conditions are common among migrant farm workers in North Carolina. The quality of housing conditions, particularly hot, dry indoor thermal environment, demonstrated significant associations with pruritus, rash, and scaling. The impact of housing characteristics on pruritus and blisters was greatest in new migrant farm workers. Further research is needed to delineate additional housing factors that could cause or exacerbate skin diseases in farm workers.

Ultrasound for carpal tunnel syndrome screening in manual laborers

INTRODUCTION

Manual laborers are at increased risk for carpal tunnel syndrome (CTS), and a combination of history, physical examination, and nerve conduction studies is often used to screen for CTS in this population. Neuromuscular ultrasound may be a better screening tool, because it is painless. In this study we compare the accuracy of nerve conduction studies and ultrasound for CTS screening.

METHODS

Five hundred thirteen manual laborers were screened prospectively for CTS using nerve conduction studies and neuromuscular ultrasound, and the accuracy of the 2 techniques was compared using the Katz hand diagram as the diagnostic standard.

RESULTS

The ROC curves for the 2 techniques were not significantly different (P = 0.542), indicating that the approaches had similar diagnostic accuracy.

CONCLUSIONS

Neuromuscular ultrasound is a painless technique that has diagnostic accuracy similar to nerve conduction studies and can be used to screen large populations at risk for CTS.

Medical skepticism and complementary therapy use among older rural African-Americans and Whites

PURPOSE

This study documents demographic, health, and complementary therapy (CT) correlates of medical skepticism among rural older adults.

METHODS

Older (≥65 years) African Americans and Whites in rural North Carolina (N=198) were interviewed. Medical skepticism was assessed using the four items from the Medical Expenditure Survey. Bivariate associations between medical skepticism and demographic and health characteristics and CT use were assessed, and independent effects on CT use.

FINDINGS

Positive responses to medical skepticism questions ranged from 19.7% (can overcome illness without help) to 59.6% (believes own behavior determines their health). Medical skepticism indicators were associated with few demographic and health characteristics, and one CT category.

CONCLUSIONS

This study shows a high degree of medical skepticism among rural older adults, but limited associations with demographic and health characteristics and CT use. Further research is needed to understand relationships of attitudes towards conventional care and CT use in this population.

Patterns of Complementary Therapy Use for Symptom Management for Older Rural Adults with Diabetes

Studies on complementary therapy use among adults with diabetes are limited by crude use measures and lack of specificity of use for treating diabetes. Data are from a study including baseline and repeated 3-day assessments of complementary therapy use among rural African American and White older (age ≥64) adults (n=71). Most commonly used complementary therapies for diabetes at baseline included prayer (88.7%), food/beverages (50.7%), herbs (11.3%) and home remedies (9.9%). In repeated measures (1131 interviews), prayer was used on 57.2% of days, followed by food/beverages (12.7%), herbs (3.4%) and home remedies (2.7%). 56.3% who reported praying did so on ≥5 reporting periods; other complementary therapy use was sporadic. These data show, with the exception of prayer and food/beverages, limited complementary therapy use for diabetes treatment among rural older adults, and less inconsistent use patterns of most complementary therapies. Further research is needed to understand the motivations and patterns of complementary therapy use for diabetes patients.

Dermatologist-diagnosed skin diseases among immigrant Latino poultry processors and other manual workers in North Carolina, USA

BACKGROUND

Immigrant Latino workers represent an expanding workforce in rural areas of the USA, where their employment is concentrated in occupations such as poultry processing that entail chemical, infectious, and mechanical skin exposures. Occupation-related skin illnesses in this vulnerable population are not well characterized.

OBJECTIVES

This study was designed to describe the prevalences of skin diseases among immigrant Latino poultry processors and other manual workers in North Carolina.

METHODS

Community-based sampling was used to recruit 742 immigrant Latino workers, 518 of whom underwent a physical examination supervised by a board-certified dermatologist. The presence or absence of skin disease on the face, neck, arms, hands, and feet was recorded.

RESULTS

Workers ranged in age from 18 years to 68 years. Slightly over half of the sample were male (52.6%). Poultry workers represented 55.8% of the study sample. Infectious skin diseases were the most common diagnosis, present in 52.3% of workers. Inflammatory skin diseases were present in 28.2% and pigmentary disorders in 21.8% of workers. The most common skin conditions were tinea pedis (37.6%), onychomycosis (31.9%), scars (13.7%), acne (11.8%), and melasma (9.3%). Age, sex, first language, and work as a poultry processor accounted in part for the prevalence of these diseases.

CONCLUSIONS

Several skin diseases are highly prevalent in immigrant Latino workers and may relate to work environment. These may impair the quality of life of these workers and predispose them to further illness.

Feasibility of interactive voice response methods in health behavior research with immigrant Latinos

OBJECTIVES

Determine the feasibility of using interactive voice response (IVR) for conducting daily diary research with immigrant Latinos.

METHODS

Baseline data containing demographic, health, and job-related characteristics were obtained from immigrant Latino construction workers (N=119). Participants also completed an IVR-based daily diary for 21 consecutive days.

RESULTS

Over one third (37%) of the sample adhered to the 21-day protocol; a comparable percent-age (38.7%) initiated but did not adhere to the protocol; and 24% never began the diary protocol. Adherence was generally not predicted by demographic, health, or job-related characteristics.

CONCLUSIONS

IVR technology makes diary studies with Latino samples feasible.

A Bayesian Multiple Imputation Method for Handling Longitudinal Pesticide Data with Values below the Limit of Detection

Environmental and biomedical research often produces data below the limit of detection (LOD), or left-censored data. Imputing explicit values for values < LOD in a multivariate setting, such as with longitudinal data, is difficult using a likelihood-based approach. A Bayesian multiple imputation (MI) method is introduced to handle left-censored multivariate data. A Gibbs sampler, which uses an iterative process, is employed to simulate the target multivariate distribution within a Bayesian framework. Following convergence, multiple plausible data sets are generated for analysis by standard statistical methods outside of a Bayesian framework. With explicit imputed values available variables can be analyzed as outcomes or predictors. We illustrate a practical application using longitudinal data from the Community Participatory Approach to Measuring Farmworker Pesticide Exposure (PACE3) study to evaluate the association between urinary acephate concentrations (indicating pesticide exposure) and self-reported potential pesticide poisoning symptoms. Additionally, a simulation study is used to evaluate the sampling property of the estimators for distributional parameters as well as regression coefficients estimated with the generalized estimating equation (GEE) approach. Results demonstrated that the Bayesian MI estimates performed well in most settings, and we recommend the use of this valid and feasible approach to analyze multivariate data with values < LOD.

Prevalence of epicondylitis, rotator cuff syndrome, and low back pain in Latino poultry workers and manual laborers

BACKGROUND

The goal of this study is to improve understanding of immigrant Latino manual workers' occupational health, focusing on upper body musculoskeletal injury.

METHODS

Physical exams were conducted with a representative sample of 516 Latino poultry workers and manual laborers in western North Carolina; outcome measures were prevalence of epicondylitis, rotator cuff syndrome, and low back pain.

RESULTS

Low back pain (n = 89; 17.2%) and rotator cuff syndrome (n = 76; 14.7%) indicated by physical exam was common. Epicondylitis was less common, but still frequent (n = 30; 5.8%). Prevalence of each outcome did not differ between poultry processing workers and other manual workers. Workers >40 years old had greater incidence of rotator cuff syndrome and epicondylitis.

CONCLUSIONS

Epicondylitis, rotator cuff syndrome, and low back pain are common in immigrant Latino workers, and may negatively impact long-term health and contribute to occupational health disparities.

3-D jobs and health disparities: The health implications of Latino chicken catchers' working conditions

OBJECTIVES

This study uses qualitative data to describe the tasks performed by chicken catchers, their organization of work, and possible health and safety hazards encountered.

METHODS

Twenty-one Latino immigrant chicken catchers for North Carolina poultry-processing plants were interviewed to obtain their perceptions of the job and its hazards. Interviews were recorded and transcribed (n = 10) or detailed notes recorded (n = 11). Transcripts and notes were subjected to qualitative analysis.

RESULTS

Chicken catching takes place in a highly contaminated and hazardous work environment. The fast pace of work, low level of control over work intensity, and piece rate compensation all result in high potential for work-related injury and illness, including trauma, electrical shock, respiratory effects, musculoskeletal injuries, and drug use. Workers receive little safety or job training.

CONCLUSIONS

Chicken catching is characterized by a work environment and organization of work that promote injury and illness.

Upper body musculoskeletal symptoms of Latino poultry processing workers and a comparison group of Latino manual workers

BACKGROUND

Upper body musculoskeletal injuries are often attributed to rapid work pace and repetitive motions. These job features are common in poultry processing, an industry that relies on Latino immigrants. Few studies document the symptom burden of immigrant Latinos employed in poultry processing or other manual jobs.

METHODS

Latino poultry processing workers (n = 403) and a comparison population of 339 Latino manual workers reported symptoms for six upper body sites during interviews. We tabulated symptoms and explored factors associated with symptom counts.

RESULTS

Back symptoms and wrist/hand symptoms lasting more than 1-day were reported by over 35% of workers. Poultry processing workers reported more symptoms than comparison workers, especially wrist and elbow symptoms. The number of sites at which workers reported symptoms was elevated for overtime workers and workers who spoke an indigenous language during childhood.

CONCLUSION

Workplace conditions facing poultry processing and indigenous language speaking workers deserve further exploration.

Employer, use of personal protective equipment, and work safety climate: Latino poultry processing workers

BACKGROUND

This analysis describes the work safety climate of Latino poultry processing workers and notes differences by worker personal characteristics and employer; describes the use of common personal protective equipment (PPE) among workers; and examines the associations of work safety climate with use of common PPE.

METHODS

Data are from a cross-sectional study of 403 Latino poultry processing workers in western North Carolina.

RESULTS

Work safety climate differed little by personal characteristics, but it did differ consistently by employer. Provision of PPE varied; for example, 27.2% of participants were provide with eye protection at no cost, 57.0% were provided with hand protection at no cost, and 84.7% were provided with protective clothing at no cost. PPE use varied by type. Provision of PPE at no cost was associated with lower work safety climate; this result was counter-intuitive. Consistent use of PPE was associated with higher work safety climate.

CONCLUSIONS

Work safety climate is important for improving workplace safety for immigrant workers. Research among immigrant workers should document work safety climate for different employers and industries, and delineate how work safety climate affects safety behavior and injuries.

Cooking and eating facilities in migrant farmworker housing in North Carolina

OBJECTIVES

We sought to (1) describe observed cooking and eating facilities in migrant farmworker camps, (2) compare observed conditions with existing farmworker housing regulations, and (3) examine associations of violations with camp characteristics.

METHODS

We collected data in 182 farmworker camps in eastern North Carolina during the 2010 agricultural season. We compared our observations with 15 kitchen-related housing regulations specified by federal and state housing standards.

RESULTS

We observed violations of 8 regulations in at least 10% of camps: improper refrigerator temperature (65.5%), cockroach infestation (45.9%), contaminated water (34.4%), rodent infestation (28.9%), improper flooring (25.8%), unsanitary conditions (21.2%), improper fire extinguisher (19.9%), and holes or leaks in walls (12.1%). Logistic regression showed that violations were related to the time of the agricultural season, housing type, number of dwellings and residents, and presence of workers with H-2A visas.

CONCLUSIONS

Cooking and eating facilities for migrant farmworkers fail to comply with regulations in a substantial number of camps. Greater enforcement of regulations, particularly during occupancy during the agricultural season, is needed to protect farmworkers.

A pilot feasibility study of a questionnaire to determine European Union-wide CAM use

BACKGROUND

No questionnaire specifically measuring the core components of complementary and alternative medicine (CAM) use has been validated for use across European Union (EU) countries. We aimed to determine the face validity, acceptability and the participants' comprehension of a pre-existing questionnaire designed to measure 'CAM use', to provide a comparative, standardised questionnaire for use by health care providers, policy makers and purchasers throughout Europe.

METHODS

Established procedures were employed to translate the questionnaire into 4 EU languages. The translated questionnaires were piloted on 50 healthy adults from each country who may never have used CAM. 10 participants per country also took part in audio-recorded think aloud interviews about the questionnaire. The interviews were transcribed and analysed in the language in which they were conducted; findings were summarised in English. Questionnaire data were pooled across countries, and patterns of completion and missing data were analysed.

RESULTS

The questionnaire was translated into Italian, Spanish, Dutch and Romanian. The mean age of the participants was 43.6 years. 34% were male, 87.4% were either light or heavy CAM users, and 12.6% were non-users. Qualitative analysis identified common problems across countries including a 'hard-to-read' layout, misunderstood terminology and uncertainty in choosing response options. Quantitative analysis confirmed that a substantial minority of respondents failed to follow questionnaire instructions and that some questions had substantial rates of missing data.

CONCLUSIONS

The I-CAM-Q has low face validity and low acceptability, and is likely to produce biased estimates of CAM use if applied in England, Romania, Italy, The Netherlands or Spain. Further work is required to develop the layout, terms, some response options and instructions for completion before it can be used across the EU.

Safety, security, hygiene and privacy in migrant farmworker housing

Safety, security, hygiene, and privacy in migrant farmworker housing have not previously been documented, yet these attributes are important for farmworker quality of life and dignity. This analysis describes the safety, security, hygiene, and privacy of migrant farmworker housing and delineates camp characteristics that are associated with these attributes, using data collected in 183 eastern North Carolina migrant farmworker camps in 2010. Migrant farmworker housing is deficient. For example, 73.8 percent of housing had structural damage and 52.7 percent had indoor temperatures that were not safe. Farmworkers in 83.5 percent of the housing reported that they did not feel they or their possessions were secure. Bathing or toileting privacy was absent in 46.2 percent of the housing. Camps with residents having H-2A visas or North Carolina Department of Labor certificates of inspection posted had better safety, security, and hygiene. Regulations addressing the quality of migrant farmworker housing are needed.

Pachydermodactyly from repetitive motion in poultry processing workers: a report of 2 cases

BACKGROUND

Pachydermodactyly is a rare, benign, acquired form of digital fibromatosis. The etiology of pachydermodactyly is unknown but is believed to be due to repeated mechanical injury of the skin. We report 2 cases identified in poultry processing workers and review other conditions associated with these cutaneous findings.

OBSERVATIONS

The 2 workers in this report were employed as a chicken catcher and a chicken hanger. On examination, both workers had marked lateral thickening of the digits, with associated pain and pruritus. The workers' skin condition developed despite the use of protective gloves, and their symptoms improved when removed from work. However, the swelling due to fibromatosis persisted.

CONCLUSIONS

Similar cutaneous findings have been reported in other occupations exposing individuals to repetitive skin trauma, and many patients demonstrating a compulsive habit of hand manipulation. This supports the conclusion that pachydermodactyly in these patients reflects repeated skin trauma. Repetitive mechanical injury in the poultry processing environment can result in considerable compensatory tissue changes. Preventive measures are needed to protect workers.

Evaluating the effectiveness of a lay health promoter-led, community-based participatory pesticide safety intervention with farmworker families

Pesticide safety training is mandated for migrant and seasonal farmworkers. However, none is required for family members, who implement home sanitation to protect against pesticide exposure and need to control pests in substandard housing. Controlled studies have demonstrated the efficacy of pesticide education programs for farmworker families, but no carefully evaluated demonstration projects have shown effectiveness in public health settings. This project evaluates a lay health promoter program to improve pesticide-related knowledge and practices. Promotoras from six agencies recruited families with children to deliver a six-lesson, in-home, culturally and educationally appropriate curriculum. Independently conducted pre- and posttests evaluated changes in knowledge and practices. Adults in 610 families completed the study. Most were from Mexico, with low levels of formal education. Significant improvements in knowledge were observed for all six lessons. Significant improvements were observed in practices related to para-occupational exposure and residential pest control. Lay health promoters with limited training and supervision can have significant impacts on families' knowledge and practices. They represent a workforce increasingly recognized as a force for reducing health disparities by providing culturally appropriate health education and other services. This study adds to the literature by demonstrating their effectiveness in a public health setting with rigorous evaluation.

Occupational eye injuries experienced by migrant farmworkers

Migrant farmworkers in North Carolina (n = 300) reported eye injuries, circumstances of injuries, and outcomes during lifetime U.S. agriculture work. Seventeen injuries were reported by 15 farmworkers; five resulted in lost work time. Most reported injuries were penetrating or open wounds, often caused by branches or other foreign objects. Injuries were seldom reported to employers; and treatment at clinics, when received, was often delayed. The incidence rate of lost work-time injuries of 23.8/10,000 worker years (95% confidence interval 7.5, 55.9), exceeds the 2009 national incidence rate (6.9/10,000). Migrant farmworkers constitute a vulnerable population; better occupational safety protections should be considered.

The quality of drinking water in North Carolina farmworker camps

OBJECTIVES

The purpose of this study was to assess water quality in migrant farmworker camps in North Carolina and determine associations of water quality with migrant farmworker housing characteristics.

METHODS

We collected data from 181 farmworker camps in eastern North Carolina during the 2010 agricultural season. Water samples were tested using the Total Coliform Rule (TCR) and housing characteristics were assessed using North Carolina Department of Labor standards.

RESULTS

A total of 61 (34%) of 181 camps failed the TCR. Total coliform bacteria were found in all 61 camps, with Escherichia coli also being detected in 2. Water quality was not associated with farmworker housing characteristics or with access to registered public water supplies. Multiple official violations of water quality standards had been reported for the registered public water supplies.

CONCLUSIONS

Water supplied to farmworker camps often does not comply with current standards and poses a great risk to the physical health of farmworkers and surrounding communities. Expansion of water monitoring to more camps and changes to the regulations such as testing during occupancy and stronger enforcement are needed to secure water safety.

Occupational injury and work organization among immigrant Latino residential construction workers

BACKGROUND

Rates of occupational injury among immigrant workers are widely believed to be underestimated. The goal of this study was to enhance understanding of the burden of occupational injury and the work organization factors underlying injury among immigrant Latino residential construction workers.

METHODS

Prospective data were obtained from a community-based sample of Latino residential construction workers (N = 107) over a 3-month period.

RESULTS

Twenty-eight participants were injured, resulting in an injury incidence rate of 55.0/100 FTE (95% CI = 41.4-71.6) during the 3-month observation period. The injury rate involving days away from work during the observation period was 3.9/100 FTE (CI = 0.2-7.2). Injuries were elevated among roofers relative to framers and general construction workers. Roofers had elevated exposure to a variety of deleterious work organization factors.

CONCLUSIONS

Although imprecise given the small sample, our results suggest a threefold to fourfold underestimate of the injury burden to immigrant Latino construction workers. Work organization may contribute to elevated rates of non-fatal occupational injury, particularly among roofers.

Stress and cognitive function in Latino farmworkers

BACKGROUND

Job stress has been associated with cognitive function, but the relationship is often overlooked when considering occupational health and safety issues of farmworkers. This study examined the relationship between stress and change in stress with change in cognitive function in a representative sample of 123 Latino farmworkers.

METHODS

A prospective study design was used in which stress and cognitive function data were collected at baseline and at 3-month follow-up. Linear regression models were used for analyses. Potential confounders included baseline gender, age, education, number of years worked in U.S. agriculture, ever smoking status, self-rated health, and depressive symptoms.

RESULTS

Baseline stress was significantly correlated with baseline cognitive function (r = -0.27; P < 0.001). Adjusting for confounders, increased baseline stress was associated with greater decline in cognitive function (P = 0.024). Short-term changes in stress were not associated with cognitive change in this cohort.

CONCLUSIONS

Stress at work is an important risk factor for poor cognitive function. This analysis suggests several implications for the provision of health care and for the organization of work for farmworkers.

Work safety climate and safety practices among immigrant Latino residential construction workers

BACKGROUND

Latino residential construction workers experience high rates of occupational fatality and injury. Work safety climate is an especially important consideration for improving the safety of these immigrant workers. This analysis describes work safety climate among Latino residential construction workers, delineates differences in work safety climate by personal and employment characteristics, and determines associations of work safety climate with specific work safety behaviors.

METHODS

Data are from a cross-sectional survey of 119 Latino residential framers, roofers, and general construction workers in western North Carolina; 90 of these participants also provided longitudinal daily diary data for up to 21 days using an Interactive Voice Response (IVR) system. Measures included the Perceived Safety Climate Scale, and daily reports of five individual and five collective safety practices.

RESULTS

Work safety climate was mixed among workers, with roofers (19.9) having lower levels than framers (24.3) or general construction workers (24.3). Days reported for several individual (glove-related risks, not doing something known to be unsafe) and collective safety practices (attended daily safety meeting, not needing to use damaged equipment, not seeing coworker create an unsafe situation) were positively associated with work safety climate.

CONCLUSIONS

Work safety climate predicts subsequent safety behaviors among Latino residential construction workers, with differences by trade being particularly important. Interventions are needed to improve safety training for employers as well as workers. Further research should expand the number of workers and trades involved in analyses of work safety climate.

Social integration and diabetes management among rural older adults

OBJECTIVE

To describe diabetes management behaviors and social integration among older adults, and delineate the associations of social integration with diabetes management behaviors.

METHOD

Interview data from 563 African American, American Indian, and White participants (age 60+) from eight south central North Carolina counties selected using a site-based procedure. Statistical analysis comprises descriptive statistics, bivariate analysis, and multivariate analysis.

RESULTS

Participants had high levels of social integration and largely adhered to diabetes management behaviors (glucose monitoring, checking feet, maintaining diet, formal exercise program, health provider monitoring A1C and examining feet). Social integration was associated with several behaviors; social network size, particularly other relatives seen and spoken with on the telephone, was associated with provider A1C monitoring and foot examinations.

DISCUSSION

Social integration had small but significant associations with diabetes management behaviors. This analysis suggests specific mechanisms for how social integration influences the effect of disease on disability.

Poultry processing work and respiratory health of Latino men and women in North Carolina

OBJECTIVE

To evaluate associations between poultry processing work and respiratory health among working Latino men and women in North Carolina.

METHODS

Between May 2009 and November 2010, 402 poultry processing workers and 339 workers in a comparison population completed interviewer-administered questionnaires. Of these participants, 279 poultry processing workers and 222 workers in the comparison population also completed spirometry testing to provide measurements of forced expiratory volume in 1 second and forced vital capacity.

RESULTS

Nine percent of poultry processing workers and 10% of workers in the comparison population reported current asthma. Relative to the comparison population, adjusted mean forced expiratory volume in 1 second and forced vital capacity were lower in the poultry processing population, particularly among men who reported sanitation job activities.

CONCLUSIONS

Despite the low prevalence of respiratory symptoms reported, poultry processing work may affect lung function.

Older adults' self-management of daily symptoms: complementary therapies, self-care, and medical care

OBJECTIVES

To describe older adults' use of complementary therapies, self-care practices, and medical care to treat daily symptoms and to delineate gender, ethnic, age, and education differences.

METHOD

A total of 200 African American and White participants (age 65+) selected using a site-based procedure complete a baseline interview and up to six sets of three daily follow-up interviews at monthly intervals. The percent of older adults using a therapy and the frequency with which therapies are used are considered.

RESULTS

The use of complementary therapies to treat daily symptoms, though important, is substantially less than the use of self-care practices and medical care. Participants differed by age, ethnicity, and education in the use of therapies.

DISCUSSION

In considering the percentage of individuals who use a therapy and the frequency with which therapies are used, this analysis adds a new dimension to understanding how older adults manage daily symptoms. Older adults are selective in their use of health self-management.

Comparing Two Questionnaires for Eliciting CAM Use in a Multi-Ethnic US Population of Older Adults

INTRODUCTION: The NAFKAM International CAM Questionnaire (I-CAM-Q) was designed to facilitate cross-study comparisons of CAM usage. This research presents the first empirical study of the I-CAM-Q's performance. MATERIALS AND METHODS: Data were collected in two studies in a multi-ethnic (African American, American Indian, and white) population of older adults in the US. In 2010, 564 adults 60+ years were recruited. The I-CAM-Q was interviewer-administered. Data were compared to those collected in 2002 from a random sample of 701 Medicare recipients 65+ years. The 2002 survey included an extensive inventory of specific CAM therapies derived from local ethnographic research. Comparisons of the responses for 14 CAM modalities common to the two studies used logistic regression adjusted for demographics. RESULTS: There were no significant differences between the 2002 and 2010 surveys in the proportions reporting 10 modalities, including use of chiropractors, homeopaths, acupuncturists, herbalists, spiritual healers, vitamins, minerals, homeopathic remedies, Qigong, visualization, and prayer for health. Significantly less use of physicians and more use of relaxation techniques were reported in 2010. Herb use and garlic, as a specific herb, were reported significantly less in 2010. CONCLUSIONS: Overall, the I-CAM-Q obtained results similar to those produced by a population-specific questionnaire. Those differences observed appear to reflect differences in the studies' inclusion criteria or secular trends in CAM. This study supports the intention of the I-CAM-Q to substitute for local and regional surveys in order to allow cross-study comparisons of CAM use. Further tests, preferably through contemporaneous data collection are needed in other populations.

Work safety climate, musculoskeletal discomfort, working while injured, and depression among migrant farmworkers in North Carolina

OBJECTIVES

This analysis described Latino migrant farmworkers' work safety climate and its association with musculoskeletal discomfort, working while injured or ill, and depressive symptoms.

METHODS

Data were from a cross-sectional survey of 300 farmworkers conducted in North Carolina in 2009. Generalized estimating equations models were used to investigate the association of work safety climate with health and safety outcomes.

RESULTS

Farmworkers perceived their work safety climate to be poor. About 40% had elevated musculoskeletal discomfort, 5.0% had worked at least 1 day while injured or ill, and 27.9% had elevated depressive symptoms. The odds of elevated musculoskeletal discomfort were 12% lower and the odds of working while injured or ill were 15% lower with each 1-unit increase in the work safety climate. Work safety climate was not associated with depressive symptoms.

CONCLUSIONS

Work safety climate was important for agricultural workers. Poor work safety climate was associated with health outcomes (musculoskeletal discomfort) and safety (working while injured or ill). Interventions to improve work safety climate in agriculture are needed, with these interventions being directed to employers and workers.

A multilevel assessment of barriers to adoption of Dietary Approaches to Stop Hypertension (DASH) among African Americans of low socioeconomic status

BACKGROUND

We examined perceptions of Dietary Approaches to Stop Hypertension (DASH) and the food environment among African Americans (AA) with high blood pressure living in two low-income communities and objectively assessed local food outlets.

METHODS

Focus groups were conducted with 30 AAs; participants discussed DASH and the availability of healthy foods in their community. Sessions were transcribed and themes identified. Fifty-four stores and 114 restaurants were assessed using the Nutrition Environment Measures Survey (NEMS).

RESULTS

Common themes included poor availability, quality, and cost of healthy foods; tension between following DASH and feeding other family members; and lack of congruity between their preferred foods and DASH. Food outlets in majority AA census tracts had lower NEMS scores (stores: -11.7, p=.01, restaurants: -8.3, p=.001) compared with majority White areas.

CONCLUSIONS

Interventions promoting DASH among lower income AAs should reflect the food customs, economic concerns, and food available in communities.

Dental care utilization among North Carolina rural older adults

OBJECTIVES

This analysis delineates the predisposing, need, and enabling factors that are associated with regular and recent dental care in a multiethnic sample of rural older adults.

METHODS

A cross-sectional, comprehensive, oral-health survey conducted with a random, multiethnic (African American, American Indian, white) sample of 635 community-dwelling adults aged 60 years and older was completed in two rural southern counties. Logistic regression models assessed the simultaneous associations of dental care with predisposing, enabling, and need factors.

RESULTS

Almost no edentulous rural older adults received dental care; 27.1 percent of dentate rural older adults had received regular dental care, and 36.7 percent had received recent dental care. Predisposing (less than high-school education, dental anxiety), enabling (no regular place for dental care), and need factors (no filled teeth) reduced the odds of regular dental, while predisposing (dental anxiety), enabling (no regular place for dental care), and need factors (no filled teeth) reduced the odds of recent dental care. Having excellent, very good, or good self-rated oral health increased the odds of receiving regular and recent dental care.

CONCLUSIONS

Regular and recent dental care are infrequent among rural older adults. Contrary to expectations, those not receiving dental care are those who most need care; this has been referred to as the Paradox of Dental Need. Community access to dental care and the ability of older adults to pay for dental care must be addressed by public-health policy to improve the health and quality of life of older adults in rural communities.

Migrant farmworker housing regulation violations in North Carolina

BACKGROUND

The quality of housing provided to migrant farmworkers is often criticized, but few studies have investigated these housing conditions. This analysis examines housing regulation violations experienced by migrant farmworkers in North Carolina, and the associations of camp characteristics with the presence of housing violations.

METHODS

Data were collected in183 eastern North Carolina migrant farmworker camps in 2010. Housing regulation violations for the domains of camp, sleeping room, bathroom, kitchen, laundry room, and general housing, as well as total violations were assessed using North Carolina Department of Labor standards.

RESULTS

Violations of housing regulations were common, ranging from 4 to 22 per camp. Housing regulation violations were common in all domains; the mean number of camp violations was 1.6, of sleeping room violations was 3.8, of bathroom violations was 4.5, of kitchen violations was 2.3, of laundry room violations was 1.2, and of general housing violations was 3.1. The mean number of total housing violations was 11.4. Several camp characteristics were consistently associated with the number of violations; camps with workers having H-2A visas, with North Carolina Department of Labor Certificates of Inspection posted, and assessed early in the season had fewer violations.

CONCLUSIONS

These results argue for regulatory changes to improve the quality of housing provided to migrant farmworkers, including stronger regulations and the more vigorous enforcement of existing regulations.

The relationship between cognitive function and non-prescribed therapy use in older adults

OBJECTIVES

To examine the association of cognitive function with use of non-prescribed therapies for managing acute and chronic conditions, and to determine whether use of non-prescribed therapies changes over time in relation to baseline cognitive function.

METHODS

200 community-dwelling adults aged 65 and older were recruited from three counties in south central North Carolina. Repeated measures of daily symptoms and treatment were collected on three consecutive days at intervals of at least one month. The Mini-Mental State Examination, the primary cognitive measure, was collected as part of the baseline survey. Data were collected on the daily use of common non-prescribed therapies (use of prayer, ignore symptoms, over-the-counter remedies, food and beverage therapies, home remedies, and vitamin, herb, or supplements) on each of the three days of the follow-up interviews for up to six consecutive months.

RESULTS

Older adults with poorer cognitive function were more likely to pray and ignore symptoms on days that they experienced acute symptoms. Poorer cognitive function was associated with increased use of home remedies for treating symptoms related to existing chronic conditions.

CONCLUSIONS

Cognitive function may play a role in why older patients use some non-prescribed therapies in response to acute and chronic conditions.

Wages, wage violations, and pesticide safety experienced by migrant farmworkers in North Carolina

Farmworkers have the potential to receive wages that fail to meet minimum wage standards. This analysis describes wages and minimum wage violations among farmworkers, and it determines associations of wage violations with personal characteristics and pesticide safety regulation violations. Data are from a cross-sectional survey of 300 eastern North Carolina farmworkers conducted in June through August, 2009. Most farmworkers (90.0%) were paid by the hour, but 11.7 percent received piece-rate pay. Wage violations were prevalent among farmworkers: 18.3 percent of all farmworkers, 45.3 percent of farmworkers without H-2A visas, and 3.6 percent of farmworkers with H-2A visas experienced wage violations. Most farmworkers experienced numerous pesticide safety violations. Personal characteristics were not associated with wage violations among farmworkers without H-2A visas, but some pesticide safety violations were associated with wage violations. The association of violations indicates that some growers generally violate regulations. Greater enforcement of all regulations is needed.

Social control in older adults' diabetes self management and well-being

The "dual effects" hypothesis argues that social control can be effective in promoting positive health-related behavior change, but it can also jeopardize the targeted individual's well-being. This hypothesis is tested using hemoglobin A1C as an objective indicator of behavioral compliance with diabetes self-management behavior and depressive symptoms. Differences in the effects of social control on A1C and depressive symptoms by sex and ethnicity are tested. Cross-sectional data were obtained from a multi-ethnic sample of older adults with diabetes (N = 593). Greater social control was associated with poorer rather than better odds of achieving glucose control, and with greater depressive symptoms. There was no evidence that social control has differential effects on either glucose control or depressive symptoms by sex or ethnicity. Active use of social control attempts by family members and friends, especially if they are coercive or punitive in nature, are likely counterproductive for maintaining the physical and mental health of older adults with diabetes.

A cross-sectional exploration of excessive daytime sleepiness, depression, and musculoskeletal pain among migrant farmworkers

In this study the authors estimated the prevalence of elevated daytime sleepiness, depressive symptoms, and musculoskeletal pain among Latino migrant farmworkers, and examined the relationship among these symptoms. Data are from a cross-sectional survey of migrant farmworkers (N = 300) conducted in eastern North Carolina in 2009. Eleven percent of Latino farmworkers reported elevated levels of daytime sleepiness, 28% reported elevated levels of depressive symptoms, and 5% reported moderate to severe musculoskeletal pain on a daily or weekly basis. Depressive symptoms and daytime sleepiness were positively associated. Depression and daytime sleepiness may increase risk of injury; further research regarding sleep issues is warranted.

Cultural basis for diabetes-related beliefs among low- and high-education African American, American Indian, and white older adults

OBJECTIVES

Racial and ethnic disparities in diabetes and subsequent complications are often attributed to culture; however, previous diabetes disparities research is restricted to in-depth ethnic-specific samples or to comparative study designs with limited belief assessment. The goal of our study was to improve understanding of the cultural basis for variation in diabetes beliefs.

DESIGN

Cross-sectional.

SETTING

Rural North Carolina.

PARTICIPANTS

Older adults (aged 60+) with diabetes, equally divided by ethnicity (White, African American, American Indian) and sex (N=593).

INTERVENTIONS

Guided by Explanatory Models of Illness and Cultural Consensus research traditions, trained interviewers collected data using 38 items in four diabetes belief domains: causes, symptoms, consequences, and medical management. Items were obtained from the Common Sense Model of Diabetes Inventory (CSMDI).

MAIN OUTCOME

Beliefs about diabetes. Response options for each diabetes belief item were "agree," "disagree" and "don't know." Collected data were analyzed using Anthropac (version 4.98) and Latent Gold (version 4.5) programs.

RESULTS

There is substantial similarity in diabetes beliefs among African Americans, American Indians and Whites. Diabetes beliefs were most similar in the symptoms and consequences domains compared to beliefs pertaining to causes and medical management. Although some discrete beliefs differed by ethnicity, systematic differences by ethnicity were observed for specific educational groups.

CONCLUSIONS

Socioeconomic conditions influence diabetes beliefs rather than ethnicity per se.

Employer provision of personal protective equipment to Latino workers in North Carolina residential construction

Despite federal regulations requiring provision of personal protective equipment (PPE) without cost to workers in the United States, very little is known about whether immigrant Latino construction workers receive no-cost PPE from their employers, and the role that employer provision plays in regular use of PPE. This study used cross-sectional data from a community-based sample of 119 Latino construction workers in western North Carolina to document receipt of employer-provided PPE by construction workers, investigate sources of variation in the receipt of employer-paid PPE, and delineate associations of employer-paid PPE with workers' regular use of PPE. The results suggest that the residential construction subsector generally fails to provide workers with PPE at no cost, as is required by regulation. Analyses also suggest that recent immigrants are least likely to receive no-cost, employer-provided PPE, and that when employers do provide no-cost PPE, Latino construction workers are more likely to use it regularly.

The association of mental conditions with blood glucose levels in older adults with diabetes

OBJECTIVES

People with diabetes must engage in several self-care activities to manage blood glucose; cognitive function and other affective disorders may affect self-care behaviors. We examined the executive function domain of cognition, depressive symptoms, and symptoms of generalized anxiety disorder (GAD) to determine which common mental conditions can co-occur with diabetes are associated with blood glucose levels.

METHODS

We conducted a cross-sectional in-person survey of 563 rural older adults (age 60 years or older) with diabetes that included African Americans, American Indians, and Whites from eight counties in south-central North Carolina. Hemoglobin A1C (A1C) was measured from a finger-stick blood sample to assess blood glucose control. Executive function, depressive symptoms, and symptoms of GAD were assessed using established measures and scoring procedures. Separate multivariate linear regression models were used to examine the association of executive function, depressive symptoms, and symptoms of GAD with A1C.

RESULTS

Adjusting for potential confounders including age, gender, education, ethnicity, marital status, history of stroke, heart disease, hypertension, diabetes knowledge, and duration of diabetes, executive function was significantly associated with A1C levels: every one-unit increase in executive function was associated with a 0.23 lower A1C value (p = 0.02). Symptoms of depression and GAD were not associated with A1C levels.

CONCLUSIONS

Low executive function is potentially a barrier to self-care, the cornerstone of managing blood glucose levels. Training aids that compensate for cognitive impairments may be essential for achieving effective glucose control.

Correlates of mental health among Latino farmworkers in North Carolina

PURPOSE

Latino farmworkers are a vulnerable population who confront multiple threats to their mental health. Informed by the stress-process model of psychiatric disorder, the goal of this paper is to determine primary and context-specific stressors of poor mental health among Latino farmworkers.

METHODS

Structured interview data were obtained from farmworkers (N = 69) in 6 counties in eastern and western North Carolina.

FINDINGS

Results indicated that a substantial number of farmworkers have poor mental health, as indicated by elevated depressive symptoms (52.2%) and anxiety (16.4%). Results also indicated that each mental health outcome had different predictors.

CONCLUSION

Addressing the mental health issues of farmworkers requires a comprehensive, multifaceted approach.

Daily symptom management practices for arthritis used by older adults

OBJECTIVE

This article describes the daily self-management practices of older adults with arthritis and examines the association of symptom experience with the use of self-management behaviors.

METHOD

197 African American and White participants completed a baseline interview and six sets of three follow-up daily-diary interviews at monthly intervals.

RESULTS

Arthritis was reported by 63.5%. Arthritis self-management reported included complementary therapies, over-the-counter (OTC) and prescription medications, foods or beverages, and home remedies. Odds of implementing these self-care practices were greater on days with joint pain, swelling, and stiffness. Although, 78.0% and 72.4% of all participants reported staying in bed or cutting back on activities in response to joint symptoms, these self-management activities were not associated with having arthritis.

CONCLUSIONS

Focusing on daily responses to symptoms demonstrates that older adults actively manage arthritis symptoms using a wide variety of measures, including complementary therapies.

Occurrence and co-occurrence of types of complementary and alternative medicine use by age, gender, ethnicity, and education among adults in the United States: the 2002 National Health Interview Survey (NHIS)

BACKGROUND

There are widespread assumptions that a large proportion of American adults use a variety of complementary and alternative medicine (CAM) therapies. The goal of this study is to explore the clustering or linkages among CAM categories in the general population. Linkset analysis and data from the 2002 National Health Interview Survey (NHIS) were used to address two specific aims. First, the dominant linkages of CAM categories used by the same individual were delineated, and population estimates were generated of the percentage of American adults using different linksets of CAM categories. Second, it was determined whether dominant linkages of CAM modalities differ by age, gender, ethnicity, and education.

METHODS

Linkset analysis, a method of estimating co-occurrence beyond chance, was used on data from the 2002 NHIS (N = 29,862) to identify possible sets of CAM use.

RESULTS

Most adults use CAM therapies from a single category. Approximately 20% of adults combined two CAM categories, with the combination of mind-body therapies and biologically based therapies estimated to be most common. Only 5% of adults use therapies representing three or more CAM categories. Combining therapies across multiple CAM categories was more common among those 46-64, women, whites, and those with a college education.

CONCLUSIONS

The results of this study allow researchers to refine descriptions of CAM use in the adult population. Most adults do not use a wide assortment of CAM; most use therapies within a single CAM category. Sets of CAM use were found to differ by age, gender, ethnicity, and education in ways consistent with previous research.

Measuring differential beliefs in complementary therapy research: an exploration of the Complementary and Alternative Medicine Beliefs Inventory (CAMBI)

The Complementary and Alternative Medicine Beliefs Inventory (CAMBI) was developed to provide a comprehensive measure of beliefs believed to differentiate complementary therapy (CT) users from nonusers. The initial evaluation of the CAMBI was based on a relatively homogeneous sample of CT users, which raises questions about its applicability in more generalized samples. This study uses data from a community-based sample of older adults (N=200) to evaluate the utility of the CAMBI in more diverse samples. Results indicated substantial variation in responses to items with each of a priori belief domains (i.e., perceived value of natural treatments, preference for participation in treatments, and orientation toward holistic health) and modest inter-correlation among items within each belief domain. Confirmatory factor analysis results indicated the a priori measurement structure provided a poor fit to obtained data. Post hoc analyses indicated that African Americans and those with less education had less consistent responses to items within each belief domain. Revision and additional development of the CAMBI is needed to enable its use in more diverse research samples.

Living and working safely: challenges for migrant and seasonal farmworkers

Migrant and seasonal farmworkers are essential to North Carolina agriculture, yet they experience major health risks. This commentary describes the characteristics of North Carolina farmworkers, important hazards they face, and the status of regulatory protections. Finally, it presents a summary of policy needed to protect the health of farmworkers.

Eye health and safety among Latino farmworkers

Farmworkers face a variety of risk factors for eye injuries. Measures of eye protection use and of eye safety knowledge and beliefs are based on a survey of 300 Latino farmworkers in North Carolina. Few farmworkers report using eye protection (8.3%); most (92.3%) report that employers do not provide eye protection. Approximately 70% report that they are not trained in preventing eye injuries; 81% believe that their chances of getting an eye injury are low. Many farmworkers choose to take risks in order to save time. Interventions are needed that target farmworker knowledge and beliefs about eye safety.

Dental anxiety and oral health outcomes among rural older adults

OBJECTIVES

The objective of this study is to determine the degree to which rural older adults are able to complete a measure of dental anxiety and to assess the prevalence, as well as the demographic and oral health characteristics, of individuals reporting high dental anxiety.

METHODS

A population-based sample of 635 African American, American Indian and White older adults (age ≥ 60 years) completed an in-home survey, and 362 dentate participants completed an oral examination. Dental anxiety was measured using the four-item Corah's Dental Anxiety Scale (DAS). Gender, ethnicity, age, education, and oral health outcomes were compared between those who completed all four DAS questions (completers) and those who did not (noncompleters) as well as, among completers, those with high versus low DAS scores.

RESULTS

There were 94 (14.8%) noncompleters. Noncompletion was associated with older age, lower education, being edentulous, and having gingival recession. 12.4% of DAS completers had high DAS scores, which was more common among those aged 60-70 years, women, and those with oral pain and sore or bleeding gums. In logistic regression analysis, only sore and bleeding gums had a significant association with a high DAS score (odds ratio = 2.40, 95% confidence interval 1.09-5.26).

CONCLUSIONS

About one in eight rural older adults have high dental anxiety, which is associated with poor oral health outcomes. Identifying new approaches to measure dental anxiety among a population with limited interaction with dental care providers is needed.

Depressive symptoms and sleepiness among Latino farmworkers in eastern North Carolina

Depression and sleepiness are both risk factors for occupational accidents and unintentional injury. Relatively little is known about the experiences of these risk factors in the immigrant Latino farmworker population. This analysis uses prospective panel data from a sample of Latino farmworkers in eastern North Carolina that were collected at monthly intervals during the 2008 agricultural season to (1) describe depressive symptoms and daytime sleepiness among immigrant Latino farmworkers across the agricultural season; (2) delineate associations of depressive symptoms with sleepiness across time; and (3) determine whether depressive symptoms precede sleepiness, or if sleepiness precedes depressive symptoms. Results indicated that 45% of farmworkers experienced elevated depressive symptoms across the season, whereas 20% experienced elevated sleepiness. Elevated depressive symptoms were more common among farmworkers living in barracks, and less common among those living in trailers. Sleepiness was more common among women than men. There was no evidence that depressive symptoms contributed to sleepiness, or that sleepiness contributed to depressive symptoms. The pattern of results suggests that a substantial proportion of Latino farmworkers experience levels of depressive symptoms or sleepiness that places them at risk for occupational accident or unintentional injury. The results also suggest that depressive symptoms and sleepiness do not cause each other; rather, the association of depressive symptoms with sleepiness hints at the possibility of a common physiologic mechanism such as circadian disruption.

Ethnic variation in oral health and social integration among older rural adults

This analysis examines the associations of oral health with social integration among ethnically diverse (African American, American Indian, White) rural older adults. Data are from a cross-sectional survey of 635 randomly selected community-dwelling adults aged 60+. Measures include self-rated oral health, number of teeth, number of oral health problems, social engagement, and social network size. Minority elders have poorer oral health than do White older adults. Most rural elders have substantial social engagement and social networks. Better oral health (greater number of teeth) is directly associated with social engagement, whereas the relationship of oral health to social network size is complex. The association of oral health with social engagement does not differ by ethnicity. Poorer oral health is associated with less social integration among African American, American Indian, and White elders. More research on the ways oral health affects the lives of older adults is warranted.

Men's knowledge and beliefs about colorectal cancer and 3 screenings: education, race, and screening status

OBJECTIVE

To compare how education, race, and screening status affected men's knowledge about colorectal cancer and their views of 3 screenings: the fecal occult blood test (FOBT), sigmoidoscopy, and colonoscopy.

METHODS

In-depth interviews were conducted with 65 African American and white men with diverse education backgrounds with similar numbers screened and unscreened.

RESULTS

Education was associated with knowledge about colorectal cancer and the colonoscopy. Screening status and education were related to FOBT knowledge. Men knew little about the sigmoidoscopy.

CONCLUSION

Intervention programs should tailor education about colorectal cancer and screening by educational attainment levels, not by race.

Calling the doctor: a qualitative study of patient-initiated physician consultation among rural older adults

OBJECTIVE

Guided by Leventhal's self-regulatory model and Cockerham's theory of health lifestyles, we explore two questions regarding physician consultation among elderly rural adults: What symptom characteristics prompt patient-initiated physician consultation? Do participants' accounts of responses to symptoms, including the decision to consult a physician, incorporate descriptions of change over time?

METHOD

We analyze data from semistructured in-depth interviews with 62 older rural adults.

RESULTS

Accounts of decisions to initiate contact with physicians support prior research. Some symptoms encouraged immediate consultation; others prompted periods of monitoring and lay management. Physicians were most often contacted if changes were new, unusually severe, persisted or worsened, or failed to respond to lay treatment.

DISCUSSION

We characterize participants' responses to symptoms as bricolages to highlight their construction from available materials. Incorporating the integrating concept of bricolage and Cockerham's emphasis on both general dispositions and symptom-specific responses represents an important extension of Leventhal's conceptualization of illness behavior, including patient-initiated physician consultation.