Preventing occupational exposure to pesticides: using participatory research with latino farmworkers to develop an intervention

Pesticide exposure is an occupational health hazard for migrant farmworkers. The US-EPA Worker Protection Standard (WPS) mandates training programs to prevent or reduce exposure. WPS implementation in a local context requires understanding individual, workplace, and community environmental factors that lead to exposure and influence intervention effectiveness. Participatory research within the PRECEDE-PROCEED planning framework was used to design a WPS training program for Mexican farmworkers in North Carolina cucumber and tobacco production. Research with farmworkers, farmers, health care providers, and Cooperative Extension agents identified modifiable behaviors and environmental factors, as well as structural and regulatory barriers requiring intervention. Data were gathered and analyzed through individual and group interviews, community forums, an advisory board, and a partnership between academic researchers and a community-based organization. The intervention's dominant features are (a) focus on key health behaviors, (b) relevance to local conditions, and (c) attention to issues of control in the workplace. Participatory research is effective for designing a health intervention where diverse social, cultural, political, and regulatory issues affect farmworkers' risk of exposure.

Complementary and alternative medicine use among older adults: ethnic variation

OBJECTIVE

Complementary and alternative medicine (CAM) is widely used in the United States, but information is lacking on CAM use among older minority adults. This analysis documents CAM use among Black, Hispanic, Asian, and White adults age > or =65 and delineates the importance of ethnicity in predicting CAM use.

METHODS

Data are from the 2002 National Health Interview Survey (NHIS). The 2002 NHIS oversampled Blacks and Hispanics and included a special module on CAM use. Logistic regression models were fit to examine the effects of ethnicity, sex, age, educational attainment, number of health conditions, and US census region on any CAM use and use of CAM within five major groupings.

RESULTS

27.7% of older adults use CAM, with the highest level of use among Asians (48.6%), followed by Hispanics (31.6%), Whites (27.7%), and Blacks (20.5%). Asian elders have significantly greater odds than Whites of using any CAM, alternative medical system, biologically based therapies, and mind-body medicine and lower odds of using body-based and manipulative methods. Hispanic elders have greater odds than Whites of using any CAM and biologically-based therapies. Black elders differ significantly from Whites only in their lesser use of body-based and manipulative methods. Overall, more women than men are CAM users. CAM use declines amongthose age > or =75 years.

CONCLUSION

CAM is an important component of older adults' health self-management, and research should examine how they learn about CAM and delineate the decision process in selecting CAM modalities.

Pterygium among Latino migrant farmworkers in North Carolina

The authors describe the prevalence and severity of pterygium among Latino migrant farmworkers in North Carolina and delineate its risk factors. They selected a sample of 304 farmworkers working in eastern North Carolina in 2005. Digital photographs were taken of each farmworker, including a facial view showing the eyes. Two physicians independently rated each farmworker for the presence and severity of pterygia, with an initial intercoder agreement of 91%. Sixty-eight (23.3%) participants had a pterygium in at least 1 eye; 28 (9.5%) had bilateral pterygia. Age was significantly associated with pterygia (odds ratio = 1.07; 95% confidence interval = 1.03-1.11). Research on the causes of pterygium among farmworkers is needed. In the interim, improvements in farmworkers' preventive behaviors, such as wearing ultraviolet protective lenses and brimmed hats, are reasonable and inexpensive measures.

Gender Differences in Anxiety and Depression Among Immigrant Latinos

This study determines elements of a social history that could assist primary care providers in identifying and treating anxiety and depression among immigrant Mexicans. Cross-sectional data were obtained through interviewer-administered survey questionnaires from immigrant Latinos in the United States fewer than 5 years (N = 150). Interviews were conducted by native Spanish-speakers in community settings. Mental health was measured with the Center for Epidemiologic Studies-Depression Scale (CES-D) and the Personality Assessment Inventory (PAI). Mental health in this sample was poor with nearly 40% indicating levels of anxiety and depression that may impair functioning. Social marginalization was associated with higher depression symptoms in men, and separation from family stress was associated with more depressive symptoms among women. When caring for immigrant Latinos, questions about social isolation and separation from family may provide insight into stress and its contribution to clinically significant anxiety and depression. These characteristics should also be considered when offering a treatment plan for anxiety and depression.

Health and social impacts of tobacco production

OBJECTIVES

To summarize current knowledge about the health and social consequences of tobacco production and to outline research needed to better understand these effects.

DATA SOURCES

The literature documenting the effects of tobacco production is scattered, and not always published in peer-reviewed sources. We undertook a systematic search using (1) a literature file based on over a decade of research on the health effects of tobacco work, (2) searches of computerized data bases (Medline, Science Citation Index, Agricola), (3) a review of new sources cited in literature uncovered through data base searches, and (4) professional contacts with others working on the effects of tobacco production.

DATA SYNTHESIS

The health effects of tobacco production include nicotine poisoning (green tobacco sickness), pesticide exposure, respiratory effects, musculoskeletal and other injuries. Most research has focused on nicotine poisoning. Social effects of tobacco production include social disruption for communities in which tobacco production is declining (unemployment, economic loss), and for communities in which tobacco production is being introduced (loss of local food production and local autonomy).

CONCLUSIONS

Research is needed on the effects of tobacco work on the health of women and children through exposure to nicotine and pesticides, the effects of chronic nicotine exposure on all tobacco workers, the neurotoxic effects of pesticide exposure and its relationship with mental health, and the effects of growing tobacco on using tobacco. Greater effort is needed to document the social disruption in communities that are economically dependent on tobacco production, particularly those in developing countries.

Ethnic differences in elders' home remedy use: sociostructural explanations

OBJECTIVE

To determine if ethnic differences in elders' use of home remedies are explained by structured inequalities.

METHOD

Dichotomous indicators of "food" and "other" home remedies were obtained from a randomly selected cohort of older adults with diabetes (N=701). Analyses evaluated if differences in availability of care, economic hardship, and health status explained ethnic differences in home remedy use.

RESULTS

Differences in residential location, discretionary money, and health partially explained greater home remedy use among Black and Native American elders relative to whites.

CONCLUSIONS

Ethnic differences in elders' use of home remedies are not largely attributed to socially structured inequalities.

Consumption of sugar- and fat-modified foods among rural older adults: the Rural Nutrition and Health (RUN) Study

This study examines the levels of and factors associated with consumption of sugar and fat-reduced foods in sample of rural, ethnically diverse older adults. Data were collected from 122 older adults, including demographic and health characteristics and six 24-hour recalls over 16-month period. About one-quarter of sweetened foods were modified, while intake of fat-modified foods ranged from 4.4 to 76.1%. Few differences in intake of modified foods were observed by gender and ethnic groups. Diabetes status was associated with higher use of sugar-modified foods. This study shows high level of acceptance of sugar- and fat-modified foods among rural older adults across variety of demographic and health characteristics.

Primary and specialty medical care among ethnically diverse, older rural adults with type 2 diabetes: the ELDER Diabetes Study

PURPOSE

Residents in rural communities in the United States, especially ethnic minority group members, have limited access to primary and specialty health care that is critical for diabetes management. This study examines primary and specialty medical care utilization among a rural, ethnically diverse, older adult population with diabetes.

METHODS

Data were drawn from a cross-sectional face-to-face survey of randomly selected African American (n=220), Native American (n=181), and white (n=297) Medicare beneficiaries > or =65 years old with diabetes in 2 rural counties in central North Carolina. Participants were asked about utilization of a primary care doctor and of specialists (nutritionist, diabetes specialist, eye doctor, bladder specialist, kidney specialist, heart specialist, foot specialist) in the past year.

FINDINGS

Virtually all respondents (99.0%) reported having a primary care doctor and seeing that doctor in the past year. About 42% reported seeing a doctor for diabetes-related care. On average, participants reported seeing 2 specialists in the past year, and 54% reported i seeing >1 specialist. Few reported seeing a diabetes specialist (5.7%), nutritionist (10.9%), or kidney specialist (17.5%). African Americans were more likely than others to report seeing a foot specialist (P < .01), while men were more likely than women to have seen bladder specialist (P = .02), kidney specialist (P = .001), and heart specialist (P = .004), after adjusting for potential confounders. Predictors of the number of specialists seen include gender, education, poverty status, diabetes medication use, and self-rated health.

CONCLUSIONS

These data indicate low utilization of specialty diabetes care providers across ethnic groups and reflect the importance of primary care providers in diabetes care in rural areas.

Age, race, and ethnicity in the use of complementary and alternative medicine for health self-management: evidence from the 2002 National Health Interview Survey

OBJECTIVES

Determine if complementary and alternative medicine (CAM) use for treating existing conditions and for health maintenance differs by age and ethnicity.

METHODS

Data from the 2002 National Health Interview Survey were used to operationalize distinct types of CAM in terms of (a) no use, (b) use for treatment only, (c) use for prevention only, and (d) use for both treatment and prevention. Differences in CAM use by age and ethnicity were examined using SUDAAN to adjust for design effects.

RESULTS

Associations of age with CAM use are curvilinear but differed by ethnicity. Some types of CAM are used primarily for treatment; others are used for health maintenance.

DISCUSSION

CAM use is one component of adults' overall approach to health self-management. Patterns of CAM use by age and ethnicity likely reflect differences in CAM availability and prevailing public health policies when adults began making their own health-related decisions.

Ethnic Disparities: Control of Glycemia, Blood Pressure, and LDL Cholesterol Among US Adults with Type 2 Diabetes

OBJECTIVE:

To examine ethnic disparities in the quality of diabetes care among adults with diabetes in the US through a systematic qualitative review.

DATA SOURCES:

Material published in the English language was searched from 1993 through June 2003 using PubMed, Web of Science, Cumulative Index to Nursing and Allied Health, the Cochrane Library, Combined Health Information Database, and Education Resources Information Center.

STUDY SELECTION AND DATA EXTRACTION:

Studies of patients with diabetes in which at least 50% of study participants were ethnic minorities and studies that made ethnic group comparisons were eligible. Research on individuals having prediabetes, those <18 years of age, or women with gestational diabetes were excluded. Reviewers used a reproducible search strategy. A standardized abstraction and grading of articles for publication source and content were used. Data on glycemia, blood pressure, and low-density lipoprotein cholesterol (LDL-C) were extracted in patients with diabetes. A total of 390 studies were reviewed, with 78 meeting inclusion criteria.

DATA SYNTHESIS:

Ethnic minorities had poorer outcomes of care than non-Hispanic whites. These disparities were most pronounced for glycemic control and least evident for LDL-C control. Most studies showed blood pressure to be poorly controlled among ethnic minorities.

CONCLUSIONS:

Control of risk factors for diabetes (glycemia, blood pressure, LDL-C) is challenging and requires routine assessment. These findings indicate that additional efforts are needed to promote diabetes quality of care among minority populations.

Neurobehavioral performance in preschool children from agricultural and non-agricultural communities in Oregon and North Carolina

Organophosphate (OP) pesticides produce acute toxic effects but little is known about low-level chronic exposures. Latino children of agricultural workers have a high risk of exposure to pesticides because of the close proximity of their homes to fields where pesticides are applied and from take-home exposure. Neurobehavioral performance of preschool children from agricultural (AG) communities was compared to performance of those from non-agricultural (Non-AG) communities in Oregon and North Carolina. Seventy-eight children aged 48-71 months completed a battery of neurobehavioral tests two times, approximately 1 month apart. Multiple regression revealed that the AG children performed poorer on measures of response speed (Finger Tapping) and latency (Match-to-Sample) compared to the Non-AG children. These results demonstrate modest differences in AG children compared to Non-AG children that are consistent with functional effects seen in adults exposed to low concentrations of OP pesticides. Just as was the case following early research on adults poisoned by pesticides, this study points to the need for additional investigations to test the hypothesis that low-concentration OP exposures affect acquisition of test performance, response speed and latency in children of agricultural workers.

Spanish dermatological vocabulary used by Mexican workers

Spanish is the second most common language spoken in the United States. Physicians can expect a growing population of patients who speak Spanish as their primary language. The purpose of this study was to develop a glossary of Spanish dermatological vocabulary commonly used by Mexican workers. Dermatologic terms were gathered from transcripts of in-depth interviews with 31 Latino farmworkers in North Carolina. Participants were asked to name and define words related to skin irritations. Farmworkers provided several definitions of some terms, and several Spanish equivalents exist for specific English words. This glossary is a supplement to other resources for learning medical Spanish and expands health care professionals' knowledge of dermatology-related Spanish vocabulary.

Aging and eating in the rural, southern United States: beliefs about salt and its effect on health

This paper draws upon qualitative research conducted among older adults in the rural, southern United States in which they articulated their beliefs and experiences with nutrition and foods, and lay models of the connection of diet with chronic disease. Salt emerged as a focus of contention. The goals of the paper are to (1) present the culturally constructed meaning of salt, (2) contrast the cultural meaning with biomedical views, and (3) discuss how these findings can be applied to health education and better doctor-patient communication. Data were collected in two rural communities characterized by high rates of poverty and a high proportion of minority residents. A total of 116 African American, Native American and white adults aged 60 years and older participated in 55 in-depth interviews or seven focus groups. A systematic analysis of text showed that salt was a highly contested component of food. While valued for its role in traditional foods and cuisine, it also held negative connotations because of biomedical links to chronic diseases prevalent in the population. We suggest that attempts to control salt intake are made difficult by the changes in taste perceptions that accompany aging. Respondents' articulation of salt's role in health and disease shows cross-over among different chronic diseases and a lay interpretation of blood as the medium through which salt affects disease. These older adults' narratives demonstrate their attempts to reconcile the important role of traditional foods in their identity as Southerners with their attempts to meet medical recommendations for healthy eating.

A qualitative review of studies of diabetes preventive care among minority patients in the United States, 1993-2003

OBJECTIVE

To review existing data to determine whether ethnic disparities exist for diabetes-related preventive care among adults in the United States.

STUDY DESIGN

Literature review.

METHODS

We identified diabetes-related studies published between 1993 and 2003, using a reproducible search strategy. Studies were selected for review if there were ethnic comparisons or if data on a specific ethnic minority were reported. From these studies, we extracted data on commonly accepted diabetes-related preventive-care measures (testing for glycemia, eye examinations, foot examinations, lipid profile, influenza vaccination, nephropathy assessment, smoking-cessation counseling). The sources were US healthcare facilities, national survey samples, Veterans Affairs facilities, Medicare databases, and managed care data.

RESULTS

Thirty-six studies met our search criteria. Data were extracted on glycemia testing (15 studies), eye examination rates (27 studies), foot examination rates (18 studies), lipid-profile assessment (15 studies), percentage of patients receiving influenza vaccinations (8 studies), nephropathy assessment (7 studies), and counseling referrals for smoking cessation (4 studies). The majority of the data indicated that the rates of diabetes monitoring are generally low regardless of the population being studied. The major ethnic differences reported were lower rates of eye examination, influenza vaccination, and lipid-profile testing among Hispanics and African Americans than among non-Hispanic whites.

CONCLUSIONS

Despite the availability of evidence-based guidelines, rates of diabetes preventive care are low, particularly for some measures in ethnic minority groups. Additional data are needed to further elucidate these disparities.

Effect of alendronate on the age-specific incidence of symptomatic osteoporotic fractures

Analyses of data from 3658 postmenopausal women with osteoporosis enrolled in the Fracture Intervention Trial showed that alendronate is effective in reducing the risk of symptomatic osteoporotic fractures across a spectrum of ages.

INTRODUCTION

Most osteoporosis studies examine the relative risk of fracture based on the entire duration of treatment. Because older patients tend to be at higher risk for osteoporosis-related fractures, this analysis examined the effect of alendronate treatment on the relative risk of fracture in terms of the age that patients attained during the study.

MATERIALS AND METHODS

We studied 3658 postmenopausal women with osteoporosis 55-80 years of age at baseline enrolled in the Fracture Intervention Trial, a large randomized, double-blind, placebo-controlled study. Patients were treated with placebo or with alendronate at a daily dose of 5 mg for 2 years followed by 10 mg for an additional 1-2.5 years, and monitored for clinical fractures. Age, rather than study time, was the dynamic variable in our analysis.

RESULTS

The relative risk reductions for hip, clinical spine, and wrist fractures were constant across age groups, without evidence of a decline at older ages. Specifically, alendronate reduced the risk of clinical fracture by 53% at the hip (relative risk [RR] = 0.47; 95% CI = 0.27-0.81; p < 0.01), 45% at the spine (RR = 0.55; 95% CI = 0.37-0.83; p < 0.01), and 31% at the wrist (RR = 0.69; 95% CI = 0.50-0.98; p = 0.038). In addition, alendronate produced a significant risk reduction of 40% (RR = 0.60; 95% CI = 0.47-0.77; p < 0.01) for the composite event of clinical hip, spine, and wrist fractures. As a consequence of the constant relative risk model, the absolute risk reduction with alendronate treatment increased with age because of the age-related increase in fracture risk in the placebo group. The absolute risk reduction for the composite event (hip, spine, and wrist fractures together) for alendronate treatment versus placebo was 65, 80, 111, and 161 women with fractures per 10,000 PYR for the 55 to <65, 65 to <70, 70 to <75, and 75-85 year age groups, respectively.

CONCLUSIONS

These data show that alendronate is effective in reducing the risk of symptomatic osteoporotic fractures across a spectrum of ages. The effectiveness is somewhat greater in patients with femoral neck T score < or = -2.5 than in those with a T score < or = -2.0.

Dermatological illnesses of immigrant poultry-processing workers in North Carolina

The authors designed this study to assess skin ailments among male Latino poultry-processing workers in one plant in North Carolina. Because conditions in poultry plants expose workers to multiple agents affecting the skin, the number of skin ailments was expected to be high. A visual skin examination was conducted by a single board-certified dermatologist for 25 male workers. Dermatological Life Quality Index scores and self-reported skin treatment data were obtained through interviews. Each worker had at least one dermatological diagnosis. Infections were most common (onychomycosis, 76%; tinea pedis, 72%), followed by inflammatory diagnoses (acne, 64%). No workers had sought medical treatment. Dermatological Life Quality Index scores indicated impaired quality of life. Worker self-reports were not strongly associated with dermatologist diagnoses. Skin diseases are common among poultry workers and impact workers' quality of life; reasons for lack of medical care should be investigated.

Meta-analysis of the efficacy of alendronate for the prevention of hip fractures in postmenopausal women

Treatment with alendronate, a potent and specific inhibitor of bone resorption, is known to significantly reduce fracture risk among women with postmenopausal osteoporosis. The purpose of this meta-analysis was to assess the consistency of the effect of alendronate in reducing the risk of hip fracture among different studies and populations. Data from completed, randomized, treatment studies were pooled in a meta-analysis. The duration of the studies ranged from 1-4.5 years. The dose of alendronate ranged from 5-20 mg/day, with over 95% of patients receiving either 5 or 10 mg/day during the trials. In patients with a T-score of less than or equal to -2.0, or with a vertebral fracture, the effect on hip fracture risk consistently favored patients receiving alendronate therapy, with an overall reduction in risk of hip fracture of 45% [95% confidence interval (CI) 16% to 64%, P=0.007]. For patients who met the criteria of osteoporosis, as defined by the World Health Organization (WHO), the overall risk reduction was 55% (95% CI 29% to 72%, P=0.0008). In both analyses we performed a sensitivity analysis by removing one study at a time. The strength of the evidence was not dependent on any one study. We conclude that therapy with alendronate is associated with significant and clinically important reductions in the incidence of hip fracture in women with postmenopausal osteoporosis. The overall reduction is consistent among different patient populations.

Diabetes foot self-care practices in a rural triethnic population

PURPOSE

The purposes of this study were to assess the level of foot self-care performed in a rural, multiethnic population of older adults and to identify factors associated with foot self-care.

METHODS

The Evaluating Long-term Diabetes Self-management Among Elder Rural Adults study included a random sample of 701 African American, Native American, and white adults from 2 rural North Carolina counties. Participants completed in-home interviews, 5 foot self-care practices from the Summary of Diabetes Self-Care Activities (SDSCA), functional status measures, and measures of education and support for foot care.

RESULTS

Foot care practices/behaviors reported at least 6 days/week ranged from 35.6% for inspecting shoes to 79.2% for not soaking feet. Four independent predictors of the SDSCA summary foot care index score were observed: having been shown how to care for feet (P < .0001), female gender (P = .03), having had a doctor check nerves in feet in past year (P = .02), and not receiving support caring for feet (P = .0425).

CONCLUSIONS

These findings indicate that educating patients about foot self-care may encourage routine foot care but that those dependent on either formal or informal support to perform foot care do so less frequently than those who perform it independently.

Self-monitoring of blood glucose in a multiethnic population of rural older adults with diabetes

PURPOSE

The purpose of the study was to describe self-monitoring of blood glucose (SMBG) practices of 698 older adults with type 2 diabetes in the rural Southeast, to identify characteristics differentiating testers from nontesters, and to identify personal and support-related predictors of monitoring frequency.

METHODS

The ELDER (Evaluating Long-term Diabetes Self-management Among Elderly Rural Adults) study was a population-based, cross-sectional survey of African American, Native American, and white Medicare recipients > or =65 years with diagnosed diabetes. Data were obtained through in-home interviews. Multiple logistic regression models were used to identify factors associated with SMBG and frequency of monitoring.

RESULTS

Seventy-seven percent of respondents practiced SMBG in the previous week; 40% tested every day in that week. No ethnic differences were seen. Significant independent predictors of any SMBG were medication regimen (taking oral agents or insulin with or without oral agents) and health care provider (HCP) recommendation to test. Among those monitoring, significant independent predictors of SMBG frequency were medication regimen, HCP recommendation to test, duration of diabetes, and receiving help with testing, which was negatively associated with monitoring frequency.

CONCLUSIONS

Among rural older persons with diabetes, HCP recommendation significantly affected practicing SMBG and SMBG frequency. These findings suggest points of intervention by diabetes educators with this vulnerable population. Further research is needed to determine how older adults use SMBG data in their self-care regimen.

Prevalence and correlates of depressive symptoms among rural older African Americans, Native Americans, and whites with diabetes

OBJECTIVE

Depression is associated with morbidity, mortality, and decreased quality of life and is a well-established complication among people with diabetes. Little is known about the prevalence and correlates of depressive symptoms among older adults living in rural communities, particularly among ethnic minority groups, who are at increased risk of developing diabetes and complications.

RESEARCH DESIGN AND METHODS

Data were analyzed from the ELDER (Evaluating Long-term Diabetes Self-management Among Elder Rural Adults) diabetes study in which face-to-face interviews were conducted with 696 older (> or =65 years of age) African-American, Native American, and white men and women in two rural counties in central North Carolina.

RESULTS

Using a criterion of > or =9 on a modified CES-D (Center for Epidemiologic Study of Depression) scale, 15.8% of the sample had depressive symptoms. In bivariate analyses, depressive symptomatology was more common among women and individuals who were unmarried and had less than a high school education, fewer financial resources, more chronic conditions, more prescription medications, and lower physical functioning. In multivariate analyses, sex, education, living arrangement, BMI, number of prescription medications, number of chronic conditions, and physical functioning remained significant.

CONCLUSIONS

These results show that older rural adults with diabetes are at high risk for depressive symptoms, regardless of their ethnic group, and that certain demographic and health characteristics are important factors in this association. These findings add to the limited body of knowledge of comorbid depression in this population. Greater attention should be paid to diagnosing and treating this condition by those who provide care to these populations.

Effect of alendronate on vertebral fracture risk in women with bone mineral density T scores of-1.6 to -2.5 at the femoral neck: the Fracture Intervention Trial

OBJECTIVES

To determine the efficacy of alendronate treatment on risk of vertebral fracture in a subgroup of women from the Fracture Intervention Trial who had bone mineral density T scores between -1.6 and -2.5 at the femoral neck and to describe how soon after initiation of therapy alendronate becomes effective and whether it is consistent in women with and without existing radiographic vertebral fracture.

PATIENTS AND METHODS

From May 1992 to March 1997, postmenopausal women aged 55 to 80 years were randomized to receive alendronate at 5 mg/d for 2 years and 10 mg/d thereafter or placebo for up to 4.5 years (mean, 3.8 years) in a controlled, double-blind, multicenter study.

RESULTS

A total of 3737 postmenopausal women were included in the study, 1878 in the alendronate group and 1859 in the placebo group. Risk of vertebral fracture was significantly reduced by alendronate compared with placebo for clinical (relative risk [RR], 0.40; 95% confidence interval [CI], 0.19-0.76; P=.005) and radiographic (RR, 0.57; 95% CI, 0.41-0.81; P=-.002) fracture. The reductions in vertebral fracture risk were consistent in women with and without an existing radiographic vertebral fracture for clinical (RR, 0.34; 95% CI, 0.12-0.84; and RR, 0.46; 95% CI, 0.16-1.17; respectively) and radiographic (RR, 0.53; 95% CI, 0.34-0.82; and RR, 0.64; 95% CI, 0.38-1.10; respectively) fractures. In both groups, the effect of alendronate on clinical vertebral fracture was noted soon after therapy was initiated. The absolute risk of vertebral fracture was low in women without a baseline radiographic fracture.

CONCLUSIONS

In women with low bone mass who do not meet the bone mineral density criterion for osteoporosis, alendronate is effective in reducing the risk of vertebral fractures. The absolute benefit of this therapy in women with a T score between -1.6 and -2.5 is greater in women with an existing vertebral fracture and/or with other risk factors. The effect of alendronate occurs early.

Ethnic disparities in glycemic control among rural older adults with type 2 diabetes

Glycemic control is a predictor of diabetes-related morbidity and mortality. However, little is known about how well older adults in rural communities, with limited access to self-care resources and specialty care practitioners, control their diabetes. Even less is known about whether minority, older, rural adults are at increased risk for poor glycemic control. We analyzed data from a cross-sectional survey of randomly selected older (> or =65 years) adults with type 2 diabetes in rural North Carolina. Participants (N=693) were men and women from three ethnic groups: African American, Native American, and White. Capillary blood samples were collected for HbA1C analysis. HbA1C levels (<7%, 7%-<8%, and > or =8%) were compared across ethnic and gender groups. Two multiple logistic regression models (model 1: personal characteristics; model 2: personal and health characteristics) were used to evaluate potential predictors of HbA1C > or =7%. Overall, 36.4% had HbA1C > or =7%. Native Americans and African-American men had the highest proportion at levels of poor glycemic control (> or =7%), and African-American women and White men had the lowest. In bivariate analysis, ethnicity, living arrangements, use of medications for diabetes, having a diabetes-related healthcare visit in the past year, and duration of diabetes were significantly associated with glycemic control. In multivariate analysis (model 1), being Native American, having low income without Medicaid, and being married were associated with poor glycemic control. Adding health characteristics (model 2), longer diabetes duration and diabetes medication therapy were significant predictors. These data indicate that older ethnic minorities in rural communities are at increased risk for diabetes complications and need diabetes management strategies to improve glycemic control.

Use of complementary and alternative medicine by persons with arthritis: Results of the National Health Interview Survey

OBJECTIVE

To compare the complementary and alternative medicine (CAM) used by adults ages 45 years and older with and without arthritis, and to investigate the prevalence and predictors of CAM use by persons who report being told by a doctor they had arthritis.

METHODS

Data from the 2002 National Health Interview Survey with a supplemental section on CAM use were analyzed. Data on overall use and use by 4 CAM modalities were calculated by arthritis status. CAM use for treatment of any health condition, including arthritis, was calculated and compared by arthritis status. Logistic regression was used to identify predictors of CAM use among persons with arthritis.

RESULTS

Overall use of CAM and use of 3 of 4 major CAM categories were higher for persons who reported doctor-diagnosed arthritis compared with those without arthritis. Biologically based therapies were the most frequently reported modalities. Although persons with arthritis were more likely than those without arthritis to report using CAM for treatment, most of their CAM use was for conditions other than arthritis. Joint pain and poor functional status were the most common predictors of CAM modalities among persons with arthritis.

CONCLUSION

Health care providers of persons with arthritis should be aware that CAM use is common among their patients. A complete medication history is needed to obtain information on CAM use for all conditions.

Organophosphate Pesticide Exposure in Farmworker Family Members in Western North Carolina and Virginia: Case Comparisons

Farmworkers and their family members are exposed to pesticides in their homes as well as at work. Using a sample of nine farmworker households in western North Carolina and Virginia, this analysis describes the organophosphate (OP) pesticide urinary metabolite levels of adults and children in these households, and compares these farmworker household OP metabolite levels to the national reference data. Data from survey and in-depth interviews are analyzed to find dwelling, household, and work characteristics related to OP metabolite levels. All participants had measurable OP metabolites. Every household had a high level of OP metabolites when compared to national reference data. There were common factors among the households that could cause the high household OP exposure, including farm employment and living adjacent to agricultural fields. Factors associated with household variability in OP exposure included having a non-nuclear family structure, and, therefore, having more adult males who were employed doing farm work, living in rental housing, not owning a vacuum cleaner, residing in a dwelling that is difficult to clean, and the season (spring versus summer) in which urine samples were collected. These results indicate that regulatory changes that improve low income housing, improve industrial hygiene standards, and provide farmworkers information about their pesticide exposure are needed to protect farmworkers and their families.

Household food security among migrant and seasonal latino farmworkers in North Carolina

OBJECTIVE

Food insecurity is defined as lack of access at all times, due to economic barriers, to enough food for an active and healthy lifestyle. The objective of this study was threefold: to characterize levels of food security, food insecurity, and hunger among migrant and seasonal Latino farmworkers; to assess predictors of food insecurity for this group; and to describe the strategies farmworkers use to cope with food insecurity.

METHODS

Adults from 102 farmworker households in North Carolina responded to a survey that used a Spanish-language adaptation of the U.S. Household Food Security Survey Module and questions about sociodemographic characteristics and food behaviors. Twenty-five farmworkers participated in in-depth interviews in which they described their households' food security situation and coping strategies.

RESULTS

Forty-eight of the 102 sample households (47.1%) were classified as food insecure, including 10 (9.8%) with moderate hunger and five (4.9%) with severe hunger. Households with children had a significantly higher prevalence of food insecurity than those without children (56.4% vs. 36.2%). Households with children accessed food programs such as the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) that were unavailable to those without children, while those without children were more likely to access food pantries and to consume wild game or fish. Coping strategies included borrowing money, reducing food variety, and adults consuming less food to protect children from hunger. Food insecurity was more than four times as prevalent among farmworker households as among the general U.S. population.

CONCLUSION

Policy changes to increase economic resources and access to federal programs are needed to decrease this food insecurity.

Profiles of people with type 2 diabetes mellitus: the extremes of glycemic control

For people with diabetes, hemoglobin A1c (HbA1c) is a measure of blood glucose control and an indication of the risk of developing diabetes complications. However, a given HbA1c value does not provide information about the diabetes self-management practices or philosophies of individuals in poor (HbA1c > 8.0%) or excellent (HbA1c < 6.5%) control. To contrast the experiences and attitudes of people at the extremes of glycemic control, interviews were conducted among 44 individuals (40-65 years old) diagnosed with diabetes for over 1 year. The participants were identified based upon their HbA1c value from a larger sample of people with type 2 diabetes that included African Americans, women, and persons with low income. Narratives were analyzed using a case-based and conceptually clustered matrix approach. The life course concept (life histories and natural transitions in roles and responsibilities across the life span) and the explanatory model of illness (individuals' beliefs about the causes, consequences, and treatment of a disease) provided the framework for the interview guide and the analysis of the narratives. Two self-management philosophy groups emerged from participants with excellent control (Committed [n = 15] and Tentative [ n = 7]) and three groups were identified among the poorly controlled group (Hopeful [n = 8], Hassled [n = 6 ], and Overwhelmed [n = 8]). Perseverance, coping skills, and age at diagnosis were life course concepts that distinguished participants within these groups. From the explanatory model of illness, beliefs about the cause of the disease, physical changes, and accepting the consequence of the disease influenced differences in these self-management philosophies. The profiles of people at the extremes of glycemic control can help those treating people with diabetes or seeking to improve self-management interventions understand differences in self-management philosophies and concentrate on specific issues hindering self-care control.

Reporting pesticide assessment results to farmworker families: development, implementation, and evaluation of a risk communication strategy

The collection of environmental samples presents a responsibility to return information to the affected participants. Explaining complex and often ambiguous scientific information to a lay audience is a challenge. As shown by environmental justice research, this audience frequently has limited formal education, increasing the challenge for researchers to explain the data collected, the risk indicated by the findings, and action the affected community should take. In this study we describe the development and implementation of a risk communication strategy for environmental pesticide samples collected in the homes of Latino/a migrant and seasonal farmworkers in a community-based participatory research project. The communication strategy was developed with community input and was based on face-to-face meetings with members of participating households. Using visual displays of data effectively conveyed information about individual household contamination and placed it in the context of community findings. The lack of national reference data and definitive standards for action necessitated a simplified risk message. We review the strengths and weaknesses of such an approach and suggest areas for future research in risk communication to communities affected by environmental health risks.

Agricultural and residential pesticides in wipe samples from farmworker family residences in North Carolina and Virginia

Children of farmworkers can be exposed to pesticides through multiple pathways, including agricultural take-home and drift as well as residential applications. Because farmworker families often live in poor-quality housing, the exposure from residential pesticide use may be substantial. We measured eight locally reported agricultural pesticides and 13 pesticides commonly found in U.S. houses in residences of 41 farmworker families with at least one child < 7 years of age in western North Carolina and Virginia. Wipe samples were taken from floor surfaces, toys, and children's hands. We also collected interview data on possible predictors of pesticide presence, including characteristics of the household residents, cleaning practices, and characteristics of the home. All families were Spanish-speaking, primarily from Mexico. Results indicate that six agricultural and 11 residential pesticides were found in the homes, with agricultural, residential, or both present in 95% of homes sampled. In general, residential pesticides were more commonly found. Presence of both types of pesticides on the floor was positively associated with detection on toys or hands. Agricultural pesticide detection was associated with housing adjacent to agricultural fields. Residential pesticide detection was associated with houses judged difficult to clean. Although the likelihood of agricultural pesticide exposure has been considered high for farmworker families, these results indicate that residential pesticide use and exposure in this population merit further study.

Food consumption patterns of rural older African American, Native American, and white adults in North Carolina

This paper describes the major food sources of selected nutrients for an ethnically diverse sample of older adults in rural North Carolina. A representative sample of 130 elders (> 70 years) completed semi-quantitative food frequency questionnaires. Percentages of foods most frequently consumed as the lead source of seven nutrients were calculated overall, by gender and ethnic group. Foods eaten at least one time per week were identified, and percentages of participants consuming that frequency were calculated. Major food sources included: salad oil/cooking oil for calories, total fat and saturated fat; miscellaneous vegetables for dietary fiber and folate; and orange/grapefruit juice for vitamin C. Heterogeneity in food sources was greatest for zinc and least for vitamin C. Variation across gender and ethnic groups was observed only in the degree to which specific food sources contributed to nutrient intake. These data provide greater insight into the dietary patterns of rural elders than examining nutrient intakes.

Faith and health self-management of rural older adults

This analysis uses in-depth interview data collected from 145 African American, European American and Native American men and women aged 70 and older who reside in two rural North Carolina counties to understand the role of religious faith and prayer in the health self-management of these older adults. The analysis addresses three specific questions: how do these older adults use religion to help them manage their health; are there ethnic and gender differences in the use of religion; and are differences in health status related to differences in the use of religion? The integral role of religion in the lives of these older rural adults is an overarching theme present in the interview texts. Six major themes link religion and health self-management: (1) prayer and faith in health self-management, (2) reading the Bible, (3) church services, (4) mental and spiritual health, (5) stories of physical healing, and (6) ambivalence. Faith and religious activities provide an anchor in the lives of these older adults. There is little variation in the use of religion for health self-management by gender, ethnicity or health status. These results suggest that the strength of religion in rural culture may limit the effectiveness of general religiosity scales to discern the relationship of religion to health and health behavior in rural populations.

North Carolina Growers' and Extension Agents' Perceptions of Latino Farmworker Pesticide Exposure

Pesticide exposure poses a significant health hazard to everyone who works in agriculture. Growers have more control over their own exposure risk than do the farmworkers they employ. While growers are responsible for providing a safe work environment, their perceptions of the health risk of pesticides influence the amount and quality of safety training and protection they offer to workers. This paper analyzes growers' and cooperative extension agents' perceptions of farmworker pesticide exposure. Data are from in-depth interviews conducted with growers and extension agents who work in western North Carolina. Both groups indicated that the danger of pesticide exposure is exaggerated by the media and the public. They feel that workers are at little risk of exposure because they have received training and protective equipment as required by law and because they are not in direct contact with chemicals. Their perceptions are at odds with results of other research indicating many farmworkers have not received the required training and do not always utilize protective gear. Linguistic and cultural barriers contribute to this discrepancy in perceptions and must be addressed if measures to reduce farmworker pesticide exposure are to be effective.

Tobacco use among Mexican farmworkers working in tobacco: implications for agromedicine

This survey evaluated tobacco use of migrant tobacco workers in eastern North Carolina. Sixty-nine (38%) out of 181 mostly male, Mexican farmworkers were smokers. Compared to non-smokers, three times more smokers reported alcohol use in the past week (p=0.002). More smokers compared to non-smokers reported poor to fair health, and fewer had worked previously in tobacco agriculture, but these differences were not statistically significant. Also not statistically significant, those smokers who were older and those who understood the most English smoked more cigarettes per day. Because farmworkers are exposed to many non-tobacco respiratory irritants, and because of the health risks of smoking, those who smoke should be urged to quit.

Detecting patterns of occupational illness clustering with alternating logistic regressions applied to longitudinal data

In longitudinal surveillance studies of occupational illnesses, sickness episodes are recorded for workers over time. Since observations on the same worker are typically more similar than observations from different workers, statistical analysis must take into account the intraworker association due to workers' repeated measures. Additionally, when workers are employed in groups or clusters, observations from workers in the same workplace are typically more similar than observations from workers in different workplaces. For such cluster-correlated longitudinal data, alternating logistic regressions may be used to model the pattern of occupational illness clustering. Data on 182 Latino farm workers from a 1999 North Carolina study on green tobacco sickness provided an estimated pairwise odds ratio for within-worker clustering of 3.15 (95% confidence interval (CI): 1.84, 5.41) and an estimated pairwise odds ratio for within-camp clustering of 1.90 (95% CI: 1.22, 2.97). After adjustment for risk factors, the estimated pairwise odds ratios were 2.13 (95% CI: 1.18, 3.86) and 1.41 (95% CI: 0.89, 2.24), respectively. In this paper, a comparative analysis of alternating logistic regressions with generalized estimating equations and random-effects logistic regression is presented, and the relative strengths of the three methods are discussed.

Tobacco use in a tri-ethnic population of older women in southeastern North Carolina

OBJECTIVE

While many studies have evaluated the epidemiology of tobacco use nationally and among specific populations, less is known about the epidemiology of tobacco use among elderly women. We examined the epidemiology of tobacco use among a tri-racial population of elderly women in southeastern North Carolina.

DESIGN

Survey

SETTING

Senior centers, community events, and communal meal settings in Robeson County, North Carolina.

PARTICIPANTS

Two hundred forty (240) women aged 60 and older, with approximately 80 women recruited from each ethnic group: Native American, African-American, and White.

MAIN OUTCOME MEASURES

Demographic information, health history, and use of alcohol, cigarettes, and smokeless tobacco (ST).

RESULTS

Of the total sample of 240 women, 38 (16%) were current ST users. In logistic regression analysis, current ST use was inversely associated with age and education, but positively associated with Native American or African-American ethnicity. Sixteen (17%) of the total sample were current smokers. In logistic regression, younger age and any alcohol use in the past year were associated with current smoking

CONCLUSIONS

In a tri-ethnic, community-based sample of older women, rates of current ST use were greater than national rates found among women of all ages in each ethnic group. On the other hand, rates of current smoking among these older women were lower than the national prevalence for women among all ages in these 3 respective ethnic groups. The distinctly different epidemiology of ST use vs cigarette smoking among these women high-lights the need to tailor tobacco interventions to each specific product.

An exploratory analysis of occupational skin disease among Latino migrant and seasonal farmworkers in North Carolina

Occupational skin disease is highly prevalent among all agricultural workers. However, few data exist on risk factors for occupational skin disease among migrant and seasonal farmworkers. The goal of this analysis was to further document the prevalence of occupational skin disease among Latino farmworkers and delineate risk factors. This exploratory analysis used data collected in repeated survey interviews with Latino farmworkers in North Carolina in June and July (early season) and in August and September (late season), 1999. Respondents were largely male (95%) and from Mexico (95%), with about one-third each age 18-24, 25-34, and 35 and older. About half were in the U.S. on work contracts. Independent variables included the physical environment (crops worked), the social environment (having received pesticide safety training, having a work contract), and behavior and individual characteristics (re-wearing work clothes, showering after work, age). The dependent measures were reporting having had itching or burning skin or a skin rash in the two months prior to each interview; 24% of the respondents in the early season, and 37% in the late season reported skin disease signs and symptoms during the previous two months. Those reporting signs and symptoms in the early season were more likely to report them in late season. Significant independent risk factors for skin signs and symptoms in early season were re-wearing work clothes, showering after work, and being age 35 or older. In late season, those who had not received pesticide safety training had lower odds of reporting skin disease signs and symptoms, after adjusting for other potential risk factors. This exploratory study indicates that Latino migrant and seasonal farmworkers experience a high incidence of occupational skin disease. Further research is required with improved measurement of skin disease signs and symptoms, diagnosis of specific skin disease, and improved measurement of risk factors.

Water safety among Latino farmworkers in North Carolina

Latinos constitute the vast majority of North Carolina's farmworker population. Drowning is a significant occupational health hazard in agriculture. Recent reports also suggest a disproportionate number of drowning victims in North Carolina are Latinos. Survey data are used to examine the levels of farmworker participation in aquatic activities and water safety behaviors. Over one-third of the farmworkers reported that they did not know how to swim. About one-quarter of the farmworkers reported participation in aquatic activities, with a greater percentage of those knowing how to swim participating in these activities. Recommendations to increase farmworker water safety include providing information through their employers and health outreach workers.

High levels of transdermal nicotine exposure produce green tobacco sickness in Latino farmworkers

Green tobacco sickness (GTS) is an occupational illness that affects tobacco workers worldwide. This study tested whether GTS results from nicotine poisoning. Data collection was based on a prospective design in which 182 farmworkers were interviewed up to five times at biweekly intervals. A saliva sample was obtained at each interview. Examining four regression models in which salivary cotinine was evaluated as a mediator between behavioral risk factors and GTS, this analysis showed that nicotine causes GTS: 25 workers had 31 occurrences of GTS. Among nonsmokers, each increment increase in the natural log of cotinine increased the odds of GTS 2.11 times, adjusting for task and wet conditions. Treatment of GTS must address nicotine poisoning. GTS affects laborers with limited resources. Research must disclose the extent of this occupational illness and investigate ways to prevent it.

Farmer health beliefs about an occupational illness that affects farmworkers: the case of green tobacco sickness

Latino migrant and seasonal farmworkers, like all agricultural workers, experience high rates of occupational illness and injury. Interventions to reduce occupational injury among farmworkers must attend to the health beliefs of agricultural employers as well as employees, as employers control many aspects of the work environment. Occupational safety programs for Latino migrant and seasonal farmworkers must also be conceptually based in health behavior change and health disparities theories. We examine health beliefs of tobacco farmers about green tobacco sickness (GTS) to show the importance of delineating employer beliefs in agricultural safety. GTS is a highly prevalent occupational illness among tobacco workers that results from nicotine poisoning through dermal absorption of nicotine during cultivation and harvesting. We use qualitative methods structured by the Explanatory Models of Illness approach to identify farmer beliefs about the etiology, onset, pathophysiology, course, and treatment of GTS. Data were collected through semi-structured in-depth interviews with 15 North Carolina tobacco farmers. A computer-assisted, systematic qualitative analysis framework was applied to the interview transcripts. While tobacco farmers were generally knowledgeable about GTS, their explanatory models for this occupational illness often mis-identified its causes (heat and bending rather than nicotine) and minimized its seriousness. These models included methods of prevention that are not proven (e.g., use of anti-nausea drugs) or are more harmful than GTS (smoking cigarettes). The need for medical treatment was also discounted. Addressing each of these beliefs is important in any program to prevent GTS among farmworkers. Documenting and understanding the beliefs and knowledge of agricultural employers is an important undertaking in our efforts to reduce occupational injury and illness among farmworkers.

A CULTURALLY APPROPRIATE FARMWORKER PESTICIDE SAFETY PROGRAM

Farming is one of the most hazardous occupations in the US. Anyone who works on a farm is at risk for a variety of occupational injuries and illnesses. Hired farmworkers are often at a disadvantage for preventing injury and illness because they lack control in the workplace. Over the past few decades, the number and percentage of US farmworkers who are immigrants, mainly from Mexico and the Latin American countries, has increased dramatically. Because many of these recently-arrived workers do not speak or read English, it is especially difficult for them to learn and implement workplace safety procedures. Safety education materials are frequently not available in Spanish, and employers are seldom bilingual.

A clinic-based, case-control comparison of green tobacco sickness among minority farmworkers: clues for prevention

BACKGROUND

Green tobacco sickness (GTS) is a highly prevalent occupational illness among tobacco workers. Working in wet tobacco is a major risk factor for GTS. Little is known about preventing GTS. This analysis examines possible GTS preventive measures.

METHODS

Data were collected from 36 patients with GTS and 40 controls who presented at clinics in eastern North Carolina in 1999 and 2000. Each participant completed an interview that included questions about their personal characteristics, work characteristics, and GTS risk factors.

RESULTS

Participants were Mexican men. Those with GTS were much less likely to have worn rain suits while working in wet tobacco and more likely to be in the United States on a work contract.

CONCLUSIONS

Wearing a rain suit while working in wet tobacco can significantly reduce the risk of GTS among tobacco workers. Care must be taken that farmworkers do not have heat stress from wearing rain suits.

Quality of diets consumed by older rural adults

Older adults residing in rural communities are at risk for low dietary quality because of a variety of social, physical and environmental circumstances. Minority elders are at additional risk because of poorer health status and lower socioeconomic status. This study evaluated the food group intake of 130 older (>70 years) African American (34%), European American (36%), and Native American (30%) residents of two rural communities in central North Carolina. An interviewer-administered food frequency questionnaire was used to measure dietary intake. Food items were classified into food groups similar to the United States Department of Agriculture (USDA) Food Guide Pyramid and the National Cancer Institutes 5 A Day for Better Health program. None of the survey participants met minimum intake recommendations and most over-consumed fats, oils, sweets and snacks. African Americans and Native Americans consumed fewer servings of meats,fruits and vegetables, and fats, oils, sweets and snacks than European Americans. African American men consumed the fewest servings of fruits and vegetables of all gender/ethnic groups. Consumption of fats, oils and sweets was greatest among those 85 years and older and was more common among denture users. National strategies to educate the public about the importance of consuming a varied diet based on the recommendations presented in national nutrition education campaigns may not be reaching older adults in rural communities, particularly minority group members.

Pesticide safety among farmworkers: perceived risk and perceived control as factors reflecting environmental justice

Farmworkers in the United States constitute a population at risk for serious environmental and occupational illness and injury as well as health disparities typically associated with poverty. Pesticides are a major source of occupational injury and illness to which farmworkers are exposed. Efforts to provide safety training for farmworkers have not been fully evaluated. Based on the Health Belief Model, this analysis examines how safety information affects perceived pesticide safety risk and control among farmworkers and how perceived risk and control affect farmworker knowledge and safety behavior. Data are based on interviews conducted in 1999 with 293 farmworkers in eastern North Carolina as part of the Preventing Agricultural Chemical Exposure in North Carolina Farmworkers' Project. Perceived pesticide risk and perceived pesticide control scales were developed from interview items. Analysis of the items and scales showed that farmworkers had fairly high levels of perceived risk from pesticides and perceived control of pesticide safety. Receiving information about pesticide safety (e.g., warning signs) reduced perceived risk and increased perceived control. Pesticide exposure knowledge was strongly related to perceived risk. However, perceived risk had a limited relationship to safety knowledge and was not related to safety behavior. Perceived control was not related to pesticide exposure knowledge, but was strongly related to safety knowledge and safety behavior. A key tenet of environmental justice is that communities must have control over their environment. These results argue that for pesticide safety education to be effective, it must address issues of farmworker control in implementing workplace pesticide safety.

Alendronate reduces the risk of multiple symptomatic fractures: results from the fracture intervention trial

OBJECTIVES

To evaluate the effect of alendronate on the occurrence rate of multiple svmptomatic fractures and on the risk of multiple symptomatic fractures (likelihood of having more than one fracture diagnosed because of the symptoms the fractures caused over the study period) among women with osteoporosis.

DESIGN

Primary analysis of data from a randomized, placebo-controlled, double-blind trial.

SETTING

Eleven community-based clinical research centers.

PARTICIPANTS

Subset of women enrolled in the Fracture Intervention Trial: aged 55 to 81 and having at least one morphometric vertebral fracture at baseline (n=2,027) or having no vertebral fracture but meeting prevailing World Health Organization bone mineral density criteria for osteoporosis (T-score < or =2.5 at the femoral neck)(n = 1,631).

INTERVENTION

All participants reporting calcium intake of 1,000 mg/day or less received a supplement of 500 mg calcium and 250 IU cholecalciferol. Participants were randomly assigned to placebo or alendronate sodium (5 mg/day for 2 years and 10 mg/day for the remainder of the study). Average total follow-up was 4.3 years.

MEASUREMENTS

Symptomatic fractures were diagnosed by personal physicians and confirmed by review of radiological data by an expert committee blinded to treatment assignments.

RESULTS

Eighty-six of 1,817 women receiving placebo experienced multiple symptomatic fractures during the follow-up period, compared with 51 of 1,841 receiving alendronate. Reduction of risk for multiple symptomatic fractures combined was 42% (relative risk (RR) = 0.58, 95% confidence interval (CI) = 0.41, 0.81) and for multiple symptomatic vertebral fractures was 84% (RR = 0.16,95% Cl = 0.05, 0.42). Cumulative incidence curves showed divergence after as little as 3 months of treatment, with a statistically significant (P = .044) reduction at 6 months for multiple symptomatic vertebral fractures. When all fractures over the follow-up period were included, the occurrence rates of all symptomatic fractures and symptomatic vertebral fractures were 34% and 63% lower, respectively, with alendronate than with placebo. These reductions were sustained during the follow-up period. All reductions in risk were consistent across predefined subgroups: age (<75 vs > or =75), morphometric vertebral fracture(present vs absent), prior clinical fracture since age 45 (yes vs no), and whether the subject had fallen in the 12 months before randomization.

CONCLUSIONS

These data demonstrate that treatment with alendronate reduces the risk of multiple symptomatic fractures during a treatment period averaging 4.3 years. The reductions were consistent across prespecified sub-groups. This effect is evident early in treatment and is sustained.

Hispanic farmworker interpretations of green tobacco sickness

This paper describes the explanatory model of green tobacco sickness (GTS) held by migrant and seasonal farmworkers in North Carolina and compares it with a research-based biobehavioral model. GTS is a form of acute nicotine poisoning that affects individuals who work in wet tobacco fields. It is characterized by nausea, vomiting, headache, and dizziness. There are no standard diagnostic criteria for GTS; clinicians must diagnose it based on a combination of symptoms and exposure risk. GTS resembles pesticide poisoning, but treatment is quite different. Many farmworkers in tobacco today are Spanish-speaking immigrants from Mexico with limited experience in tobacco work. In-depth interviews about GTS were conducted with 23 Hispanic farmworkers in central North Carolina to explore their understanding of the problem. Workers generally attributed the symptoms to other aspects of working in tobacco, such as pesticides or heat, rather than nicotine. They cited many of the same risk factors identified in the biobehavioral model, such as wet work conditions and inexperience with tobacco work. Prevention and treatment include a combination of exposure avoidance and common medications. The symptoms of most importance to farmworkers were insomnia and anorexia, both of which impaired the ability to work. This jeopardized their income, as well as their work security. If health care providers understand the explanatory model held by farmworkers, they will be more effective at diagnosing and treating GTS and be better prepared to teach patients how to prevent future episodes.

Mobility Patterns of Migrant Farmworkers in North Carolina: Implications for Occupational Health Research and Policy

Occupational health research often relies on longitudinal data to link exposures and health outcomes. Studies of migrant and seasonal farmworker health face special challenges. Farmworkers are difficult to track, and many occupational health outcomes require considerable time to develop. Using data from two longitudinal studies of farmworker health in North Carolina, we: 1) describe migration during one summer (amount, reasons, destinations); and 2) discuss the implications of these patterns for conducting different types of environmental and occupational health research. Approximately 30 percent of farmworkers migrated over the course of the summer. Analysis of specific work sites revealed both in- and out-migration. Work availability and work-related illness were major causes of out-migration. These data suggest that failing to document reasons for migration may result in underestimation of the occupational illnesses and injuries under study. If research on migrant farmworkers is to be used to establish worksite health and safety policies, traditional research designs and data analysis techniques must be adapted to the realities of worker migration.