Staying healthy: the salience and meaning of health maintenance behaviors among rural older adults in North Carolina

Beliefs about what constitutes health promoting behaviors vary by culture and class, and knowing how an older adult interprets a specific health behavior can improve health education and medical compliance. Ethnomedical approaches have investigated how people define disease and the therapies used to return to a state of health. However, little research has addressed how individuals define health, or the behaviors they use to maintain health. We analyze the behaviors elders state are needed to stay healthy, and their meanings for these behaviors. Narratives collected through in-depth interviews with 145 male and female rural North Carolina residents aged 70 and older, including African Americans, Native Americans and European Americans are analyzed using systematic text analysis. The participants' narratives include seven salient health maintenance domains: (1) Eating Right, (2) Drinking Water, (3) "Taking" Exercise, (4) Staying Busy, (5) Being with People, (6) Trusting in God and Participating in Church, and (7) Taking Care of Yourself. Several of these domains are multi-dimensional in the meanings the elders ascribe to them. There is also overlap in the content of some of the domains; they are not discrete in the minds of the elders and a specific health behavior can reflect more than one domain. Four themes cross-cut the domains: "balance and moderation", "the holistic view of health", "social integration", and "personal responsibility". Elders in these rural communities hold a definition of health that overlaps with, but is not synonymous with a biomedical model. These elders' concept of health seamlessly integrates physical, mental, spiritual, and social aspects of health, reflecting how health is embedded in the everyday experience of these elders. Staying healthy is maintaining the ability to function in a community. These results indicate that providers cannot assume that older patients will share their interpretation of general health promotion advice.

Predictors of incidence and prevalence of green tobacco sickness among Latino farmworkers in North Carolina, USA

STUDY OBJECTIVE

The characteristics of some populations make epidemiological measurement extremely difficult. The objective of this study is to identify risk factors that explain variation among incidence densities and proportions of one occupational illness, green tobacco sickness, within one such special population, Latino migrant and seasonal farmworkers in the United States.

DESIGN

Prospective cohort study.

SETTING

37 farmworker residential sites located in Granville and Wake Counties, North Carolina, USA.

PARTICIPANTS

182 migrant and seasonal farmworkers that included 178 Latino men, three Latino women, and one non-Hispanic white man.

MAIN RESULTS

Green tobacco sickness had a prevalence of 0.082, and an incidence density of events per 100 days of 1.88 among the farmworkers. Prevalence and incidence density increased from early to late agricultural season. Major risk factors included lack of work experience, work activities, and working in wet clothes. Tobacco use was protective.

CONCLUSION

Green tobacco sickness has a high incidence among migrant and seasonal farmworkers. Because workers have little control over most risk factors, further research is needed to identify ways to prevent this occupational illness.

Environmental and behavioral predictors of salivary cotinine in Latino tobacco workers

We report the results of a cohort study of 182 seasonal and migrant farmworkers engaged in tobacco production in two North Carolina counties. Data were collected on tobacco work tasks and risk factors for exposure to nicotine, including smoking, every 2 weeks over a 10-week period during the summer of 1999. Saliva samples were collected for cotinine analysis at every contact. Salivary cotinine levels increased across the season, independent of smoking status. Multivariate analyses identified a model (R2 = 0.68) in which predictors of cotinine included greater age, later-season work, wet working conditions, smoking, and work task. Harvesting ("priming") tobacco was associated with higher cotinine levels than other tasks. This study demonstrates that tobacco workers experience substantial work-related exposure to nicotine. The long-term effects of such exposure should be investigated.

The incidence of green tobacco sickness among Latino farmworkers

We estimated the prevalence and incidence density (ID) and the risk factors of green tobacco sickness among minority farmworkers in North Carolina. Using a prospective surveillance design, 182 farmworkers were interviewed up to 5 times at biweekly intervals in 1999. The green tobacco sickness prevalence was 24.2%, whereas the ID was 1.88 days per 100 days worked. Greater work experience (5+ years, ID = 0.87; first year ID = 2.41) and tobacco use (ID of 1.18 vs 2.39) were negatively associated with green tobacco sickness. Task (e.g., priming ID, 4.04; topping ID, 1.86; barning ID, 0.62) and working in wet clothing (25% of workdays ID, 2.97; fewer than 25% of workdays ID, 1.29) had the largest effect. More effort must be directed toward preventing this occupational illness that affects workers who have little control over workplace safety.

Training farmworkers about pesticide safety: issues of control

Farmworkers experience a lack of control over the conditions of their work environment. In trying to reduce the effects of exposure to pesticides, most health care providers give instructions to farmworkers about how to protect themselves. Outreach programs that target farmworkers focus on health education and recommend washing hands, wearing appropriate clothing, and avoiding direct contact. The research reported in this paper shows that farmworkers in North Carolina perceive many of these preventive measures to be outside their control. The ability of farmworkers to engage in safe practices depends on their capability to communicate with their employer, have positive work relationships, and the availability of protective equipment. The perceptions of control identified in this paper are issues that service providers and policy makers should consider to provide programs that will effectively promote pesticide safety and healthier farmworkers.

Eye symptoms and use of eye protection among seasonal and migrant farmworkers

BACKGROUND

Farmworkers face an array of environmental and workplace hazards that pose risks of eye damage from accidents involving agricultural chemicals and equipment and from exposure to wind, dust, and ultraviolet rays. Eye safety risks are known among industrial and agricultural occupations, yet little is known about the prevalence of eye symptoms and use of eye protection among farmworkers.

METHODS

A survey of 197 Latino farmworkers in North Carolina used self-report data to measure workers' prevalence of eye symptoms and eye protection use.

RESULTS

Eye pain and redness after working all day in the field were reported by more than 40% of workers. Most (98.4%) reported not wearing sunglasses when working in the fields; reasons included lack of sunglasses and interference with field tasks.

CONCLUSIONS

Eye symptoms are prevalent in this population. Failure to use eye protection indicates the need for further education and training of Latino farmworkers and their employers about occupational risks to eyesight.

Something for everyone? A community and academic partnership to address farmworker pesticide exposure in North Carolina

Partnerships between academic researchers and community organizations are frequently formed to address environmental health concerns in underserved communities. Although such participatory approaches to research combine valuable assets of both partners, they are often difficult to maintain. We describe a partnership formed to investigate migrant and seasonal farmworker exposure to pesticides in North Carolina and to develop effective interventions to reduce exposure. North Carolina ranks fifth in the United States in the number of farmworkers; most are from Mexico, and a significant minority come to the United States on work contracts. Several barriers to establishing effective collaboration were recognized in this partnership, including stereotypes, cultural differences, competing demands for time and attention, and differences in orientation to power structures. To overcome these barriers, members of the partnership took actions in three domains: clarifying the different goals of each partner, operationalizing a model of participation that could involve many different community segments developing cultural sensitivity. By taking these actions, the work of the partnership was accomplished in ways that met the criteria for success of both academic researchers and community members. This approach can be used by others to develop collaborative relationships to investigate environmental health issues within a community-based participatory framework.

Farmworker pesticide exposure and community-based participatory research: rationale and practical applications

The consequences of agricultural pesticide exposure continue to be major environmental health problems in rural communities. Community-based participatory research (CBPR) is an important approach to redressing health disparities resulting from environmental causes. In this article we introduce a collection of articles that describe projects using CBPR to address the health disparities resulting from pesticide exposure in agricultural communities, particularly the communities of migrant and seasonal farmworkers. The articles in this collection are based on a workshop convened at the 1999 American Public Health Association meeting. The goals in presenting this collection are to provide those endeavoring to initiate CBPR projects needed information, guidelines, and procedures to improve the quality of the CBPR experience; to increase the scientific validity of CBPR projects; and to reduce the potential difficulties and stress of these collaborations. In this introduction we discuss the context in which these projects operate, summarizing background information about farmworkers in the United States, what is known about farmworker pesticide exposure, and the concept of community-based participatory research. Finally, the articles in this collection are summarized, and major themes common to successful CBPR projects are identified. These common features are taking the time to interact with the community, using multiple approaches to engage the different parts of the community, understanding different participants often have different goals, appreciating each group's strengths, valuing community knowledge, and being flexible and creative in conducting research. The final article in this collection describes the translational research program at the National Institute of Environmental Health Sciences (NIEHS) highlighting activities pertinent to the health of rural communities, giving an overview of NIEHS-supported projects addressing health concerns of Native Americans and rural African-American communities in addition to farmworkers, and discussing future plans for CBPR at NIEHS.

Farmworker reports of pesticide safety and sanitation in the work environment

BACKGROUND

Migrant and seasonal farmworkers are at risk for occupational illnesses from pesticide exposure, and the effectiveness of pesticide safety regulations has not been evaluated. It is important to learn from farmworker safety experiences to develop effective measures to improve agricultural workplace safety.

METHODS

Formative research included in-depth interviews with farmworkers, farmers, extension agents, and health care providers. Survey research included interviews with 270 minority farmworkers during 1998, and 293 during 1999.

RESULTS

Farmworkers and farmers hold different beliefs concerning pesticide safety which affect sanitation practices. Farmworkers report in survey data that farmers do not adhere to regulations mandating training and basic sanitation facilities.

CONCLUSIONS

Several points of intervention are available to improve pesticide safety and sanitation. Additional regulation by itself is not an advantageous starting point. The emphasis for intervention must include educating farmers as well as farmworkers.

Pesticide Use and Safety Training in Mexico: The Experience of Farmworkers Employed in North Carolina

Migrant and seasonal farmworkers in the United States are now overwhelmingly immigrants from Mexico. Pesticide exposure among these farmworkers is a major occupational health concern; however, little research has considered the agricultural pesticide use and safety experiences of these workers in their communities of origin. This analysis uses survey data collected by the PACE project to delineate the farming and pesticide use experiences of Mexican-born farmworkers in North Carolina. Over 80 percent of the 277 Mexican-born farmworkers had done agricultural work in Mexico, including work on their own farms (93%) and as hired farm labor (35%). Almost two-thirds of those farmworkers with farming experience had used pesticides, but only about one-third of those who used pesticides had received pesticide safety training or information. Most of those who used pesticides had used some form of safety equipment. Those who had worked as hired farm labor in Mexico were more likely to have used pesticides and safety equipment, and to have received safety training and information. Those who spoke an indigenous language at home rather than Spanish were less likely to have used pesticides and to have received safety training and information. These results demonstrate that farmworkers coming to the U.S. from Mexico arrive with a variety of experiences with pesticide usage and pesticide safety training. Such experiences form the framework within which farmworkers understand the relationship of pesticide usage to human health. It is important for occupational health and safety programs directed to farmworkers in the U.S. to consider the experiences these workers bring from their communities of origin.

Vitamin and mineral supplement use by older rural adults

BACKGROUND

Vitamin and mineral supplement products are widely consumed by older adults. This study describes supplement product use in a multiethnic rural population, relates supplement usage to dietary nutrient intake, and determines predictors of supplement usage.

METHODS

Data are from a population-based sample of 130 community-dwelling adults aged 70 years and older in two rural North Carolina counties. The sample was 34% African American, 36% European American, and 30% Native American. Interviewer-administered semiquantitative food frequency questionnaires were used to obtain data on usual diet and supplement use. In-home interviews allowed verification of supplement composition. Intakes from diet and supplement products were examined for vitamins A, E, B6, C, folate, iron, zinc, and calcium.

RESULTS

Of those who participated in the study, 47% reported using one or more supplement products. African Americans were significantly less likely to take supplements than Native Americans or European Americans. Based on dietary intakes, 65% of the participants were deficient (<2/3 recommended dietary allowance [RDA]) for at least one nutrient. The use of supplement products for the eight nutrients investigated was not related to dietary nutrient deficiency. For all nutrients investigated, except iron and calcium, a greater proportion of those without dietary deficiency took a supplement product than those with deficiency. Using logistic regression, ethnicity (European American and Native American), and gender (women) were significant predictors of supplement use.

CONCLUSIONS

These findings suggest that although both dietary deficiencies of vitamins and minerals and supplement use are relatively high in this population, there is no association between supplement use and deficient dietary intakes for the eight nutrients examined. Health care providers should be aware that nutritional counseling and guidance on appropriate supplement usage is needed in this population.

On their own: nutritional self-management strategies of rural widowers

In-depth interviews conducted with 12 rural widowers participating in a population-based study of nutritional strategies of rural adults 70 years and older were analyzed to (a) identify factors that place widowers at risk for nutritional problems and (b) understand how rural residence is related to this risk. The nutritional strategies that successfully accomplished three groups of food-related tasks (food acquisition, food use, and maintaining food security) focused on one of three resource domains: self-care, informal support, and formal support. Resources that facilitated these nutritional strategies are identified, as are those conditions that led to nutritional strategies inadequate to ensure food acquisition, food use, and food security. These findings can be used to help identify rural elderly widowers who are at nutritional risk.

Farmworkers and pesticides: community-based research

In this paper we summarize the results of a workshop conducted to disseminate information about community-based research on the environmental health risks of exposure of farmworkers to pesticides. Community-based research is an approach that is advocated for addressing issues of environmental justice such as exposure of farmworkers to pesticides. This workshop brought together scientists, community organization members, and agency representatives to review and discuss the research methods and organizational relationships that have been successful in conducting past community research so these principles can be applied to new situations. The objectives of this workshop were to a) be a forum in which those conducting community-based research with farmworkers could share what they had learned; b) delineate the successes and barriers across different projects to further develop models and methods for conducting community-based research; and c) determine future directions and needs of farmworker community-based research for environmental justice.

Smokeless tobacco use among adults in the Southeast

Tobacco use is associated with numerous illnesses and contributes to as many as 400,000 deaths in the United States each year. Most tobacco use in the United States is in the form of cigarette smoking, but smokeless tobacco use is particularly high in certain areas and within certain subpopulations. Among US adults, smokeless tobacco use is associated with low socioeconomic status, male sex, Native American race, and southern or rural residence. We review six studies among adults (> or = 18 years) describing the epidemiology of smokeless tobacco use in the southeastern United States. These studies indicate that the Southeast, with its strong ties to tobacco production, is an area that requires intensive tobacco cessation strategies targeting the use of smokeless tobacco as well as cigarettes.

Migrant farmworkers and green tobacco sickness: new issues for an understudied disease

BACKGROUND

The transition from family tobacco production to dependence on hired labor has placed migrant and seasonal farmworkers (MSF) at risk for green tobacco sickness (GTS). No previous studies of GTS have focused on MSF.

METHODS

One hundred and forty-four Hispanic MSF working in tobacco production in North Carolina were surveyed to obtain self-reports of GTS, preventive behaviors, and treatments.

RESULTS

Forty-one percent reported having GTS at least once during the summer. Most had taken no precautions to prevent GTS. Ninety-six percent of those with GTS had tried to treat it. Antinausea medications were the most common treatments. Only 9% sought medical treatment; 7% lost work time.

CONCLUSIONS

The incidence of GTS obtained by interviewing MSF is much higher than that in other studies, which have relied on rates of medical treatment or farmers' reports for their workers. MSF constitute a population at risk for GTS who have little control over work conditions to prevent GTS or seek treatment.

Nutritional self-management of elderly widows in rural communities

Studies of the nutritional status of older adults (by marital status) and of older women recently widowed suggest that widows are nutritionally vulnerable. Yet few studies have examined nutrition-related behaviors among widows to see why this is true. We conceptualize these behaviors as nutritional self-management strategies, encompassing behaviors related to obtaining food, consuming it, and maintaining food security. Data come from in-depth interviews conducted with 64 widowed women age 70+ in rural North Carolina (23 African American, 24 European American, 17 Native American). Transcripts were coded and analyzed using a systematic text-analysis procedure. Length of widowhood ranged from less than 1 year to 39 years. Themes identified in recent widows' interviews and corroborated in those widowed longer indicate that there are varied responses to widowhood. Some may have a positive impact on nutritional strategies (e.g., following own dietary needs), but most are likely to be negative (e.g., meal skipping, reduced home food production, less dietary variety). Rural communities need to develop ways to identify such widows and assist them in finding acceptable ways to meet nutritional needs.

Enhancing community participation in intervention research: farmworkers and agricultural chemicals in North Carolina

The participation of affected communities in the development of public health intervention research improves project sustainability and effectiveness by making projects more relevant and acceptable to the communities. This article presents a multimode, multidomain model approach for community participation in different project components, which ensures the benefits of participation without requiring the same level of participation in every activity or by every community sector. A case study is used to illustrate the model, describing procedures for establishing and maintaining farmworker participation in developing an intervention to reduce exposure to chemicals. Farmworkers are a poor and underserved population for which the empowering and culturally appropriate benefits of community participation are especially needed. However, this population presents challenges for participatory health projects: geographic dispersion, ethnic diversity, lack of organization, sense of powerlessness, and communication and transportation difficulties. The lessons learned in this case extend the method and theory of community participation.

Implementation of EPA's Worker Protection Standard training for agricultural laborers: an evaluation using North Carolina data

The US Environmental Protection Agency has promulgated a Worker Protection Standard which requires that farmworkers receive pesticide safety training. The implementation of these regulations has not been evaluated. Using data collected through personal interviews with 270 Hispanic farmworkers recruited from 35 labor sites in an eight-county area, the authors analyzed the extent to which farmworkers received pesticide safety training, characteristics of the training, and variations in knowledge and safety behavior. Approximately a third of the farmworkers reported having ever received information or training on pesticide safety, and 25.6% reported having received training in the year in which they were interviewed. Workers with H2A visas were significantly more likely to have received training than workers without these visas. The training received varied in location, duration, and language. Most included the use of a video, as well as verbal presentation, and most included printed materials. However, few workers knew the ways in which they could be exposed to pesticides or reported using any method to protect themselves from pesticide exposure.

Agricultural Chemical Safety Training Materials for Farmworkers: Review and Annotated Bibliography

Preventing or reducing exposure to agricultural chemicals is an important focus for health educators serving migrant and seasonal farmworkers and their families. The development of the US Environmental Protection Agency Worker Protection Standard requiring that farmworkers receive pesticide-related training created a demand for culturally appropriate and effective training materials, yet no compendium of such materials exists. This paper reports the results of a search for and evaluation of training materials designed for use with farmworkers. There is considerable redundancy in the training materials currently available to health educators. Few items address the health issue of chemical residues in the fields, an important source of low level chronic chemical exposure for farmworkers. There are no published evaluations of the effectiveness of any of the materials. Our review suggests the need for further development and testing of appropriate training materials to reduce the exposure of farmworkers to agricultural chemicals.

Barriers to nutritional well-being for rural elders: community experts' perceptions

Older adults use public and private services, as well as personal resources, to meet nutritional needs. In-depth interviews conducted with 73 service providers and community experts in two rural North Carolina counties were analyzed for these experts' perceptions of barriers to adequate nutrition for older adults. Perceived barriers included characteristics of the county and programs, transportation, and kin, as well as older adult medical and economic conditions, food habits, knowledge, and attitudes. The importance given each of these domains varied by respondents' area of expertise. Community experts and providers may not see the connection between their services and nutritional well-being of older adults.

Qualitative methods in arthritis research: sampling and data analysis

Qualitative research presents unique opportunities for understanding arthritis from the perspective of those affected by the condition, as well as for critically evaluating many of the associations of traditional psychosocial variables that have emerged from decades of quantitative research. Its growing acceptance and popularity in the health sciences is reflected in the number of program announcements and other research requests that stress the need to understand health and disease in the context of human diversity. At the same time, it is important that qualitative research be done well and be critically evaluated in the same manner as quantitative research. Many of the same cautions (e.g., garbage in, garbage out) and principles (e.g., standardization of data collection and analysis steps, documentation of research activities) apply in all types of scientific inquiry. By maintaining high standards for qualitative research, those conducting and evaluating qualitative research can ensure its continued acceptance as a valid and powerful mode of research.

Occupational and Environmental Health Risks in Farm Labor

This essay provides an introduction and overview for this special thematic section. We discuss the general occupational and environmental health risks that those who provide farm labor - farmers, farm families, and farmworkers - experience as a result of commercial agriculture. We first briefly review some of the farm safety research literature, highlighting the important trend of listening to those who perform farm labor as they speak for themselves about their health and safety concerns. We then introduce the individual articles in the collection and highlight their common themes: (1) control; (2) economic stress; (3) beliefs; and (4) access to information. We conclude that applied anthropology has a key role to play in reducing occupational and environmental health risks for farm labor by conducting the research that indicates the most proximate causes of farm injury and illness, and by developing appropriate interventions to address these causes.

Chronic Agricultural Chemical Exposure Among Migrant and Seasonal Farmworkers

Laboratory studies and case reports of accidental exposure to large amounts of chemicals indicate that there are immediate and long-term negative health consequences of exposure to agricultural chemicals. Logically, the consequences of chronic low-level exposure also should, be negative. Establishing a connection, however, between the more usual (chronic, low-level) exposure experienced by farmworkers and health outcomes using epidemiological methods has been difficult. In this article we examine the reasons why this has been difficult, using specific examples from our ongoing research in rural North Carolina. We argue that because of the diverse nature of farming systems in the United States and the social organization of farm work, the combination of social-science methods for establishing the patterns of exposure and for devising appropriate measures with epidemiological methods for linking exposure to outcomes may provide the best methodological approach for studying this problem.

Farmworker and Farmer Perceptions of Farmworker Agricultural Chemical Exposure in North Carolina

Agricultural chemicals pose health risks for farmworkers engaged in cultivating and harvesting crops. In a project to develop culturally appropriate interventions to reduce farmworker exposure to agricultural chemicals, formative research used in-depth interviews and focus groups to elicit beliefs and knowledge about exposure from farmers and migrant and seasonal farmworkers in North Carolina. Farmworkers were concerned about acute effects they attributed to exposure and had little knowledge of long-term effects of low-level exposure. They believe that some individuals are inherently more susceptibility to the health effects of exposure than others; most do not recognize the skin as a site of chemical absorption. They report instances of exposure that reflect the power relationships with fanners, indicating that lackof knowledge is not the only issue that must be addressed in an intervention. Farmers believe that farmworkers are not exposed to chemicals because they do not mix or apply chemicals. Such a belief is consistent with the training received by fanners. The PRECEDE-PROCEED planning model is used to identify predisposing and reinforcing factors on which an effective intervention should focus.

Ecology of breastfeeding in the United States: An applied perspective

Breastfeeding initiation and duration have followed distinct cycles in the United States. Despite recent increases, breastfeeding rates still fall short of public health goals. This paper takes an applied perspective to examine the potential role of human biologists in enhancing the promotion of breastfeeding in the United States. The conceptual model of breastfeeding held by policy makers and public health professionals is distinguished from that of human biologists. An integrated model is proposed that incorporates the sociodemographic factors of the public health model with the components of breastfeeding structure and early mother-infant interaction of the human biology model. It is suggested that human biologists can contribute to the more effective promotion of breastfeeding by promoting inclusion of a wide range of anthropological research on infant feeding, clarifying the vocabulary of infant feeding, and expanding their own research to include participation in the development and testing of breastfeeding interventions. Am. J. Hum. Biol. 10:221-228, 1998. © 1998 Wiley-Liss, Inc.

Treatment with alendronate prevents fractures in women at highest risk: results from the Fracture Intervention Trial

BACKGROUND

The efficacy of antiresorptive therapy in preventing fractures in women at highest fracture risk, such as very elderly women or those with severe osteoporosis, is uncertain.

PARTICIPANTS AND METHODS

Using data from a double-blind, randomized, placebo-controlled clinical trial that enrolled 2027 postmenopausal women aged 55 to 81 years with low femoral neck bone mineral density (BMD) and existing vertebral fractures, we examined the consistency of the effect of treatment with alendronate sodium in preventing fractures within a priori-specified risk subgroups defined at baseline by age, bone density, number of preexisting vertebral fractures, and history of postmenopausal fracture. The women were randomized to oral administration of alendronate or placebo and followed up for an average of 2.9 years. The initial dose of alendronate sodium was 5 mg/d; the dosage was increased from 5 to 10 mg/d at 24 months. New vertebral fractures, the primary end point of this arm of the trial, were defined by morphometry as a decrease of 20% and at least 4 mm in any vertebral height between baseline and a follow-up radiograph at 36 months. Incident clinical fractures, the secondary end point, included nonspine and clinical (symptomatic) vertebral fractures. All clinical fractures were confirmed with x-ray film reports or, in the case of clinical vertebral fractures, x-ray films.

RESULTS

Overall, there was a 47% significant reduction in risk of new vertebral fractures in the alendronate group compared with the placebo group. The reduction in risk of new vertebral fracture was consistent across fracture risk categories including age (relative risk [RR], 0.49 in women < 75 years compared with 0.62 in those > or = 75 years), BMD (RR, 0.54 in women with a femoral neck BMD < 0.59 g/cm2 [median] compared with 0.53 in those with a BMD > or = 0.59 g/cm2), and number of preexisting vertebral fractures (RR, 0.58 in women with 1 vertebral fracture compared with 0.52 in those with > or = 2). The overall significant 28% reduction in risk of incident clinical fractures in the alendronate group compared with the placebo group was also observed within these subgroups. Compared with the number of lower-risk women, a similar or smaller number of high-risk women needed to be treated to prevent 1 fracture. For example, 8 women aged 75 years or older compared with 9 women younger than 75 years, or 4 women with 2 or more existing vertebral fractures compared with 16 women with 1 existing vertebral fracture, needed to be treated with alendronate for 5 years to prevent 1 new vertebral fracture.

CONCLUSIONS

Alendronate effectively reduces fracture risk in postmenopausal women with vertebral fractures and low BMD, including those women at highest risk because of advanced age or severe osteoporosis. Since the risk reductions observed with alendronate treatment were consistent within fracture risk categories, more fractures were prevented by treating women at highest risk.

Qualitative methods in arthritis research: overview and data collection

The intent of this paper has been to introduce qualitative methods to arthritis researchers and provide them with basic skills to critically evaluate results of qualitative research. Qualitative research provides the arthritis researcher with the opportunity to look at the meaning that the subject places on his or her behavior, their knowledge of their condition and of its treatment, and the meaning they infer from the actions of those around them, including their care providers and social supports. If carefully conducted, qualitative research methods can produce rich and insightful findings. We have limited our discussion to an overview of qualitative research and data collection methods. We will discuss issues related to how participants are selected and methods of data analysis in a subsequent paper.

Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group

BACKGROUND

Previous studies have shown that alendronate can increase bone mineral density (BMD) and prevent radiographically defined (morphometric) vertebral fractures. The Fracture Intervention Trial aimed to investigate the effect of alendronate on the risk of morphometric as well as clinically evident fractures in postmenopausal women with low bone mass.

METHODS

Women aged 55-81 with low femoral-neck BMD were enrolled in two study groups based on presence or absence of an existing vertebral fracture. Results for women with at least one vertebral fracture at baseline are reported here. 2027 women were randomly assigned placebo (1005) or alendronate (1022) and followed up for 36 months. The dose of alendronate (initially 5 mg daily) was increased (to 10 mg daily) at 24 months, with maintenance of the double blind. Lateral spine radiography was done at baseline and at 24 and 36 months. New vertebral fractures, the primary endpoint, were defined by morphometry as a decrease of 20% (and at least 4 mm) in at least one vertebral height between the baseline and latest follow-up radiograph. Non-spine clinical fractures were confirmed by radiographic reports. New symptomatic vertebral fractures were based on self-report and confirmed by radiography.

FINDINGS

Follow-up radiographs were obtained for 1946 women (98% of surviving participants). 78 (8.0%) of women in the alendronate group had one or more new morphometric vertebral fractures compared with 145 (15.0%) in the placebo group (relative risk 0.53 [95% Cl 0.41-0.68]). For clinically apparent vertebral fractures, the corresponding numbers were 23 (2.3%) alendronate and 50 (5.0%) placebo (relative hazard 0.45 [0.27-0.72]). The risk of any clinical fracture, the main secondary endpoint, was lower in the alendronate than in the placebo group (139 [13.6%] vs 183 [18.2%]; relative hazard 0.72 [0.58-0.90]). The relative hazards for hip fracture and wrist fracture for alendronate versus placebo were 0.49 (0.23-0.99) and 0.52 (0.31-0.87). There was no significant difference between the groups in numbers of adverse experiences, including upper-gastrointestinal disorders.

INTERPRETATION

We conclude that among women with low bone mass and existing vertebral fractures, alendronate is well tolerated and substantially reduces the frequency of morphometric and clinical vertebral fractures, as well as other clinical fractures.

Variation in nutrient intake of infants and its implications for collecting reliable dietary intake data

Sources of variance in dietary intake data for infants in the fourth to sixth months of life were examined. Twenty-eight mothers of infants in the Special Supplemental Food Program for Women, Infants, and Children gave 24-hr recall information on their infants' diets on 4 random days over approximately 1 month. ANOVA found no day of the week or sequence effects on nutrient variation. Variance was partitioned into between- and within-subject (residual) components. Interindividual variation exceeded intraindividual variation for all nutrients except vitamin C. Variance ratios ranged from 0.3 to 1.3. Calculations of 95% confidence limits for group and individual mean intakes indicated that, whereas a single recall would estimate the group mean within 20% for most nutrients, five recalls would be necessary for the same accuracy in individual means. Magnitude and patterning of variance components differ substantially from those found in studies of adults, suggesting that infant data collection strategies should be tailored to the unique nature of the infant diet.

Patterns of variation in breast-feeding behaviors

This paper describes the range and patterning of variation in specific breast-feeding behaviors among a sample of 62 American mothers, as well as the relationship of the patterns to duration of exclusive breast feeding. Infant feeding data were collected using 24-hr records completed by mothers every 8 days through the first 6 months post partum. Behaviors examined were: number of daily feedings, minimum and maximum intervals between feedings, length of feedings and total daily nursing duration. Variation in magnitude of these behaviors ranged from three- to eight-fold. Principal components analysis found this variation patterned in two dimensions, relating to feeding frequency and length of time spent breast feeding. These dimensions accounted for approximately equal proportions of variance in the breast-feeding behaviors, totaling about 80% of all variance at 4 and 8 weeks. There was significant continuity of breast-feeding styles practiced by any one woman from 4 to 8 weeks. The feeding frequency dimension was strongly associated with duration of exclusive breast feeding. Three explanations--cultural, biological and biocultural--are proposed to account for this association. It is argued that the intracultural variation in breast-feeding styles in this sample may be sufficient to cause corresponding variation in breast milk production, in part accounting for variation in duration of exclusive breast feeding. Predictions of exclusive breast-feeding duration will be most accurate for women with a breast-feeding style of infrequent feedings, while predictions for women with a style of frequent feeding will be confounded by cultural factors which have an independent effect on breast-feeding supplementation.

The effect of beikost on the diet of breast-fed infants

To clarify the role of beikost (nonmilk foods) in the diet of the breast-fed infant, 45 infants were studied longitudinally from birth to 6 months of age. All were exclusively breast fed from birth; they received beikost as their first non-breast-milk food. The infants were selected from a sample of 91 normal American infants consuming maternal-selected diets. Weight and length were measured at monthly intervals from birth. Diet data were collected using 24-hour diaries completed by mothers every eight days throughout the study. Age at introduction of first beikost averaged 120.8 days (range 36 to 178 days). When the infants were less than 4 months of age (N = 12), first consumption of beikost was accompanied by decreasing nursing frequency. In contrast, the infants who were introduced to beikost at a later age (N = 33) showed stable or increasing nursing frequency. Those apparently age-related roles of beikost as dietary "replacements" or "additions" were confirmed by growth analyses. Although groups were similar at birth and 1 month, replacement infants had significantly lower weights for length and age after 2 months. Those results suggest that for breast-fed infants, early introduction of beikost reduces milk consumption and may lead to significantly lower weight gain than continuation of the exclusive breast-milk diet.

Nutritional thriftiness and human reproduction: beyond the critical body composition hypothesis

The 'critical body composition hypothesis' (CBCH) is frequently used to explain variations in the duration of postpartum amenorrhea. The hypothesis predicts that ovulation will not occur it fat reserves fall below a critical threshold. This paper attempts to analytically separate the CBCH from the broader concept of nutritional thriftiness on which it is based. A review of previous research on fat cell metabolism and ovulation finds no direct link between fatness and fecundity. Rather they are each regulated by the lactation and mother-infant interactions associated with breast feeding. As a system which delivers available fat into breast milk and prevents ovulation only during the time when the infant is dependent on the mother, the pathways outlined here represent a nutritionally thrifty method of fertility regulation, one which maximizes reproductive success while minimizing energy investment. The cultural patterning both of infant feeding behaviors and the wider range of maternal activities which affect breast feeding suggest specific testable hypotheses to explain interpopulation variations in fertility and infant nutritional status.

Changes in maternal postpartum adiposity and infant feeding patterns

The relationship between maternal fatness and infant feeding practices was studied in 46 healthy Caucasian women from parturition to 6 months postpartum. Mothers reported infant feeding practices in diary form throughout the study. Weight, triceps and subscapular skinfolds, and midarm circumference were measured on seven occasions. Upper arm fat area was computed. All women breast fed their infants for at least 5 months, with no nonbreast milk food introduced for at least 2 months. All women had declining or stable postpartum weights. Linear regressions of upper arm fat area on days since parturition were used to ascertain overall direction of change in adiposity for each woman. Declining fat area occurred in 17 cases and was associated with a breast-feeding pattern of short frequent feeds. In the remaining 29 cases, increasing fat area was associated with significantly longer and less frequent feeds. It is hypothesized that these different fat change patterns result from differential activity of adipose tissue lipoprotein lipase, which is itself mediated by serum prolactin concentration. Relevance of these findings for resolution of the controversy surrounding the critical body composition hypothesis and lactation amenorrhea is discussed.