Racial and ethnic disparities in diabetes and subsequent complications are often attributed to culture; however, previous diabetes disparities research is restricted to in-depth ethnic-specific samples or to comparative study designs with limited belief assessment. The goal of this study is to improve understanding of the cultural basis for variation in diabetes beliefs.
Rural North Carolina
Older adults (aged 60+) with diabetes, equally divided by ethnicity (White, African American, American Indian) and gender (N=593).
Guided by Explanatory Models of Illness and Cultural Consensus research traditions, trained interviewers collected data using 38 items in four diabetes belief domains: causes, symptoms, consequences, and medical management. Items were obtained from the Common Sense Model of Diabetes Inventory (CSMDI).
Beliefs about diabetes. Response options for each diabetes belief item were “agree,” “disagree” and “don’t know”. Collected data were analyzed using Anthropac (version 4.98) and Latent Gold (version 4.5) programs.
There is substantial similarity in diabetes beliefs among African Americans, American Indians, and Whites. Diabetes beliefs were most similar in the “symptoms” and “consequences” domains compared to beliefs pertaining to “causes” and “medical management.” Although some discrete beliefs differed by ethnicity, systematic differences by ethnicity were observed for specific educational groups.
Socioeconomic conditions influence diabetes beliefs rather than “ethnicity” per se.
Diabetes Beliefs; Explanatory Models of Illness; Cultural Consensus; Ethnic Differences; Health Disparities
Cognitive impairment is common in older adults with diabetes, yet it is unclear to what extent cognitive function is associated with health literacy. We hypothesized that cognitive function, independent of education, is associated with health literacy.
The sample included 537 African American, American Indian, and White men and women 60 years or older. Measures of cognitive function included the Mini-Mental State Examination (MMSE), Verbal Fluency, Brief Attention, and Digit Span Backward tests. Health literacy was assessed using the S-TOFHLA.
Cognitive function was associated with health literacy, independent of education and other important confounders. Every unit increase in the MMSE, Digit Span Backward, Verbal Fluency or Brief Attention was associated with a 20% (p<.001), 34% (p<.001), 5% (p<.01), and 16% (p<.01) increase in the odds of having adequate health literacy, respectively.
These results suggest that cognitive function is associated with health literacy in older adults with diabetes. Because poor cognitive function may undermine health literacy, efforts to target older adults on improving health literacy should consider cognitive function as a risk factor.
cognition; health literacy; diabetes
Job stress has been associated with cognitive function, but the relationship is often overlooked when considering occupational health and safety issues of farmworkers. This study examined the relationship between stress and change in stress with change in cognitive function in a representative sample of 123 Latino farmworkers. METHODS: A prospective study design was used in which stress and cognitive function data were collected at baseline and at 3-month follow-up. Linear regression models were used for analyses. Potential confounders included baseline gender, age, education, number of years worked in U.S. agriculture, ever smoking status, self-rated health, and depressive symptoms.
Baseline stress was significantly correlated with baseline cognitive function (r = −.27; p <.001). Adjusting for confounders, increased baseline stress was associated with greater decline in cognitive function (p = .024). Short-term changes in stress were not associated with cognitive change in this cohort.
Stress at work is an important risk factor for poor cognitive function. This analysis suggests several implications for the provision of health care and for the organization of work for farmworkers.
stress; cognitive function; occupational health; farmworkers
Although the health risk to farmworkers of working in hot conditions is recognized, potential for excessive heat exposure in housing affecting rest and recovery has been ignored. We assessed heat index (HI) in common and sleeping rooms in 170 North Carolina farmworker camps across a summer and examined associations with time of summer and air conditioning use. Dangerous HIs were recorded in most rooms, regardless of time or air conditioning. Policies to reduce HI in farmworker housing should be developed.
Preparing and consuming nutritionally adequate and safe food is critical to the work capacity of migrant farmworkers. This paper: (1) describes observed cooking and eating facilities in migrant farmworker camps, (2) compares observed conditions with existing farmworker housing regulations, and (3) examines associations of violations with camp characteristics.
Data were collected in 182 farmworker camps in eastern NC during the 2010 agricultural season. Observations were compared with 15 kitchen-related housing regulations specified by federal and state housing standards.
Violations of 8 regulations were observed in at least 10% of camps: improper refrigerator temperature (65.5%), cockroach infestation (45.9%), contaminated water (34.4%), rodent infestation (28.9%), improper flooring (25.8%), unsanitary conditions (21.2%), improper fire extinguisher (19.9%), and holes/leaks in walls (12.1%). Logistic regression showed that violations were related to the time of the agricultural season, housing type, number of dwellings and residents, and presence of workers with H-2A visas.
Cooking and eating facilities for migrant farmworkers fail to comply with regulations in a substantial number of camps. Greater enforcement of regulations, particularly post-occupancy during the agricultural season, is needed to protect farmworkers.
To assess water quality in migrant farmworker camps in North Carolina (NC), and determine associations of water quality with migrant farmworker housing characteristics.
Data were collected in 181 farmworker camps in eastern NC during the 2010 agricultural season. Water samples were tested using the Total Coliform Rule (TCR) and housing characteristics were assessed using NC Department of Labor (NCDOL) standards.
A total of 61 (34%) of 181 camps failed the TCR. Total coliform bacteria were found in all 61 camps, with E. coli also being detected in 2. Water quality was not associated with farmworker housing characteristics or with access to registered public water supplies. Multiple official violations of water quality standards had been reported for the registered public water supplies.
Water supplied to farmworker camps often does not comply with current standards and poses a great risk to the physical health of farmworkers and surrounding communities. Expansion of water monitoring to more camps and changes to the regulations such as testing during occupancy and stronger enforcement are needed to secure water safety.
Safety, security, hygiene, and privacy in migrant farmworker housing have not previously been documented, yet these attributes are important for farmworker quality of life and dignity. This analysis describes the safety, security, hygiene, and privacy of migrant farmworker housing and delineates camp characteristics that are associated with these attributes, using data collected in 183 eastern North Carolina migrant farmworker camps in 2010. Migrant farmworker housing is deficient. For example, 73.8 percent of housing had structural damage and 52.7 percent had indoor temperatures that were not safe. Farmworkers in 83.5 percent of the housing reported that they did not feel they or their possessions were secure. Bathing or toileting privacy was absent in 46.2 percent of the housing. Camps with residents having H-2A visas or North Carolina Department of Labor certificates of inspection posted had better safety, security, and hygiene. Regulations addressing the quality of migrant farmworker housing are needed.
migrant farmworker; housing quality; occupational justice
Latino farmworkers are a vulnerable population who confront multiple threats to their mental health. Informed by the stress-process model of psychiatric disorder, the goal of this paper is to determine personal and situational correlates of poor mental health among Latino farmworkers. Structured interview data were obtained from farmworkers (N=69) in six counties in eastern and western North Carolina. Results indicated that a substantial number of farmworkers have poor mental health, as indicated by elevated depressive symptoms (52.2%) and anxiety (16.4%). Results also indicated that each mental health outcome had different predictors. Addressing the mental health issues of farmworkers requires a comprehensive, multifaceted approach.
The quality of housing provided to migrant farmworkers is often criticized, but few studies have investigated these housing conditions. This analysis examines housing regulation violations experienced by migrant farmworkers in North Carolina, and the associations of camp characteristics with the presence of housing violations.
Data were collected in183 eastern North Carolina migrant farmworker camps in 2010. Housing regulation violations for the domains of camp, sleeping room, bathroom, kitchen, laundry room, and general housing, as well as total violations were assessed using North Carolina Department of Labor standards.
Violations of housing regulations were common, ranging from 4 to 22 per camp. Housing regulation violations were common in all domains; the mean number of camp violations was 1.6, of sleeping room violations was 3.8, of bathroom violations was 4.5, of kitchen violations was 2.3, of laundry room violations was 1.2, and of general housing violations was 3.1. The mean number of total housing violations was 11.4. Several camp characteristics were consistently associated with the number of violations; camps with workers having H-2A visas, with North Carolina Department of Labor Certificates of Inspection posted, and assessed early in the season had fewer violations.
These results argue for regulatory changes to improve the quality of housing provided to migrant farmworkers, including stronger regulations and the more vigorous enforcement of existing regulations.
Migrant farmworker; housing conditions; substandard housing; housing standards; enforcement
To describe older adults' use of complementary therapies, self-care practices, and medical care to treat daily symptoms and to delineate gender, ethnic, age, and education differences.
A total of 200 African American and White participants (age 65+) selected using a site-based procedure complete a baseline interview and up to six sets of three daily follow-up interviews at monthly intervals. The percent of older adults using a therapy and the frequency with which therapies are used are considered.
The use of complementary therapies to treat daily symptoms, though important, is substantially less than the use of self-care practices and medical care. Participants differed by age, ethnicity, and education in the use of therapies.
In considering the percentage of individuals who use a therapy and the frequency with which therapies are used, this analysis adds a new dimension to understanding how older adults manage daily symptoms. Older adults are selective in their use of health self-management.
health self-management; complementary therapies; rural aging
This analysis delineates the predisposing, need, and enabling factors that are significantly associated with regular and recent dental care in a multi-ethnic sample of rural older adults.
A cross-sectional comprehensive oral health survey conducted with a random, multi-ethnic (African American, American Indian, white) sample of 635 community-dwelling adults aged 60 years and older was completed in two rural southern counties.
Almost no edentulous rural older adults received dental care. Slightly more than one-quarter (27.1%) of dentate rural older adults received regular dental care and slightly more than one-third (36.7%) received recent dental care. Predisposing (education) and enabling (regular place for dental care) factors associated with receiving regular and recent dental care among dentate participants point to greater resources being the driving force in receiving dental care. Contrary to expectations of the Behavioral Model of Health Services, those with the least need (e.g., better self-rated oral health) received regular dental care; this has been referred to as the Paradox of Dental Need.
Regular and recent dental care are infrequent among rural older adults. Those not receiving dental care are those who most need care. Community access to dental care and the ability of older adults to pay for dental care must be addressed by public health policy to improve the health and quality of life of older adults in rural communities.
dental care utilization; aging; gerontology; rural health; minority health; public health policy
To examine the association of cognitive function with use of non-prescribed therapies for managing acute and chronic conditions, and to determine whether use of non-prescribed therapies changes over time in relation to baseline cognitive function.
200 community-dwelling adults aged 65 and older were recruited from three counties in south central North Carolina. Repeated measures of daily symptoms and treatment were collected on three consecutive days at intervals of at least one month. The Mini-Mental State Examination (MMSE), the primary cognitive measure, was collected as part of the baseline survey. Data were collected on the daily use of common non-prescribed therapies (use of prayer, ignore symptoms, over-the-counter remedies, food and beverage therapies, home remedies, and vitamin, herb, or supplements) on each of the three days of the follow-up interviews for up to six consecutive months.
Older adults with poorer cognitive function were more likely to pray and ignore symptoms on days that they experienced acute symptoms. Poorer cognitive function was associated with increased use of home remedies for treating symptoms related to existing chronic conditions.
Cognitive function may play a role in why older patients use some non-prescribed therapies in response to acute and chronic conditions.
cognitive function; self health management; health services
Evaluate similarities and differences in the self-care domain of health lifestyle among older, rural dwelling women and men.
Qualitative analysis of in-depth interview data from 62 community-dwelling older (M = 74.3 years) African and European American women and men.
Both older women and men rely heavily on over-the-counter (OTC) medications and home remedies self-care; professional health care is typically sought when self-care is not effective. However, relative to men, women were more knowledgeable about different approaches to self-care, especially home remedies, they used a wider range of self-care activities, and they placed greater priority on self-care over professional health care.
The structure of older women’s and men’s self-care domain of health lifestyle is similar. However, there are subtle differences in health lifestyle that are likely embedded in gendered role behavior and may contribute to women’s greater health complaints.
This analysis examines the associations of oral health with social integration among ethnically diverse (African American, American Indian, white) rural older adults. Data are from a cross-sectional survey of 635 randomly selected community-dwelling adults aged 60+. Measures include self-rated oral health, number of teeth, number of oral health problems, social engagement, and social network size. Minority elders have poorer oral health than do white older adults. Most rural elders have substantial social engagement and social networks. Better oral health (greater number of teeth) is directly associated with social engagement, while the relationship of oral health to social network size is complex. The association of oral health with social engagement does not differ by ethnicity. Poorer oral health is associated with less social integration among African American, American Indian and white elders. More research on the ways oral health affects the lives of older adults is warranted.
Oral health disparities; social engagement; social network; rural aging
This study compared how education, race, and screening status affected men’s knowledge about colorectal cancer, and their views of three screenings, the fecal occult blood test (FOBT), sigmoidoscopy, and colonoscopy.
In-depth interviews were conducted with 65 African-American and white men with diverse education backgrounds with similar numbers screened and unscreened.
Education was associated with knowledge about colorectal cancer and the colonoscopy. Screening status and education were related to FOBT knowledge. Men knew little about the sigmoidoscopy.
Intervention programs should tailor education about colorectal cancer and screening by educational attainment levels, not by race.
colorectal cancer; colorectal cancer screening; health disparities; African-American
tattoo; infectious disease; Latino
Little is known about the HIV and sexually transmitted disease (STD) risk behaviors of Hispanic/Latino farmworkers. This study was designed to describe risk factors for HIV and STD infection, explore personal characteristics associated with condom use, and evaluate the feasibility of collecting self-report and biomarker data from farmworkers.
Self-report and biomarker data were collected from a sample of male farmworkers living in 29 camps in North Carolina during the 2008 growing season.
Over half of the 100 male workers, mean age 37.1 (range 19–68) years, reported binge drinking during the past 12 months. Forty percent of those who reported having had sex during the past three months indicated that they were under the influence of alcohol. Knowledge of HIV and STD transmission and prevention was low. Among the 25 workers who reported having had sex during the past three months, 16 and 2 reported using a condom consistently during vaginal and anal sex, respectively, and nearly one out of six workers reported paying a woman to have sex. Two workers tested positive for syphilis.
Farmworkers in this sample demonstrated significant HIV and STD risks; however, when exploring potential bivariate associations with consistent condom use no statistically significant associations were identified perhaps due to the small sample size. Because it was feasible to collect self-report and biomarker data related to HIV and STDs from Hispanic/Latino farmworkers, research needed to further explore risks and develop interventions to reduce disease exposure and transmission among this vulnerable population.
This paper describes research designed to specify complementary therapies used among older adults by obtaining daily use data and the specific purposes for use.
Two-hundred African American and white participants completed a baseline interview and up to six sets of three daily-diary interviews at monthly intervals.
Participants provided retrospective information on complementary therapy use, and information on the use of therapies for specific symptoms experienced across 3,070 person days. Retrospective information indicated that most participants used complementary therapies (e.g., 85.0% used home remedies in the past year). The use of complementary or other therapies and the number of days the therapies were used varied for specific symptoms. For example, home remedies were used on 86 (9.1%) of the 944 person days for which joint pain was reported.
The daily-diary design provides detailed information for delineating how elders include complementary and other therapies in their health self-management.
Health self-management; complementary therapies; rural aging
This analysis describes the association of health and functional status with private and public religious practice among ethnically diverse (African American, Native American, white) rural older adults with diabetes.
Data were collected using a population-based, cross-sectional, stratified, random sample survey of 701 community-dwelling elders with diabetes in two rural North Carolina counties. Outcome measures were private religious practice, church attendance, religious support provided, and religious support received. Correlates included religiosity, health and functional status, and personal characteristics. Statistical significance was assessed using multiple linear regression and logistic regression models.
These rural elders had high levels of religious belief, and private and public religious practice. Religiosity was associated with private and public religious practice. Health and functional status were not associated with private religious practice, but they were associated with public religious practice, such that those with limited functional status participated less in public religious practice. Ethnicity was associated with private religious practice: African Americans had higher levels of private religious practice than Native Americans or whites, while Native Americans had higher levels than whites.
Variation in private religious practice among rural older adults is related to personal characteristics and religiosity, while public religious practice is related to physical health, functional status and religiosity. Declining health may affect the social integration of rural older adults by limiting their ability to participate in a dominant social institution.
rural aging; minority aging; chronic disease; diabetes; religious participation; religiosity; social integration
Knowing a patient’s health literacy can help clinicians and researchers anticipate a patient’s ability to understand complex health regimens and deliver better patient-centered instructions and information. Poor health literacy has been linked with lower ability to function adequately in health care systems.
We evaluated and compared three measures of health literacy and performance among older patients with diabetes.
Cross-sectional study utilizing in-person interviews conducted in participants’ homes.
A tri-ethnic sample (n = 563) of African American, American Indian, and white older adults with diabetes from eight counties in south-central North Carolina.
Participants completed interviews and health literacy assessments using the Short-Form Test of Functional Health Literacy in Adults (S-TOFHLA), the Rapid Estimates of Adult Literacy in Medicine Short-Form (REALM-SF), or the Newest Vital Signs (NVS). Scores for reading comprehension and numeracy were calculated.
Over 90% completed the S-TOFHLA numeracy and approximately 85% completed the S-TOFHLA reading and REALM-SF. Only 73% completed the NVS. The correlation of S-TOFHLA total scores with REALM-SF and NVS were 0.48 and 0.54, respectively. Age, gender, ethnic, educational and income differences in health literacy emerged for several instruments, but the pattern of results across the instruments was highly variable.
A large segment of older adults is unable to complete short-form assessments of health literacy. Among those who were able to complete assessments, the REALM-SF and NVS performed comparably, but their relatively low convergence with the S-TOFHLA raises questions about instrument selection when studying health literacy of older adults.
health literacy; older adults; diabetes
To describe diabetes management behaviors and social integration among older adults, and delineate the associations of social integration with diabetes management behaviors.
Interview data from 563 African American, American Indian and white participants (age 60+) from eight south central North Carolina counties selected using a site-based procedure. Statistical analysis comprises descriptive statistics, bivariate analysis, and multivariate analysis.
Participants had high levels of social integration and largely adhered to diabetes management behaviors (glucose monitoring, checking feet, maintaining diet, formal exercise program, health provider monitoring A1C and examining feet). Social integration was associated with several behaviors; social network size, particularly other relatives seen and spoken with on the telephone, was associated with provider A1C monitoring and foot examinations.
Social integration had small but significant associations with diabetes management behaviors. This analysis suggests specific mechanisms for how social integration influences the effect of disease on disability.
Diabetes management; social integration; social engagement; social network; disablement process
The Complementary and Alternative Medicine Beliefs Inventory (CAMBI) was developed to provide a comprehensive measure of beliefs believed to differentiate complementary therapy (CT) users from nonusers. The initial evaluation of the CAMBI was based on a relatively homogeneous sample of CT users, which raises questions about its applicability in more generalized samples. This study uses data from a community-based sample of older adults (N=200) to evaluate the utility of the CAMBI in more diverse samples. Results indicated substantial variation in responses to items with each of a-priori belief domains (i.e., perceived value of natural treatments, preference for participation in treatments, and orientation toward holistic health) and modest inter-correlation among items within each belief domain. Confirmatory factor analysis results indicated the a-priori measurement structure provided a poor fit to obtained data. Post-hoc analyses indicated that African Americans and those with less education had less consistent responses to items within each belief domain. Revision and additional development of the CAMBI is needed to enable its use in more diverse research samples.
To determine the prevalence of carpal tunnel syndrome (CTS) in Latino poultry processing workers.
Symptoms and nerve conduction studies were used to prospectively assess 287 Latino poultry processing workers and 226 Latinos in other manual labor occupations.
The prevalence of CTS was higher in poultry processing (8.7%) compared to non-poultry manual workers (4.0%, p < 0.0001). The adjusted odds ratio for the prevalence of CTS in poultry workers was 2.51 (95% CI of 1.80 to 3.50) compared to non-poultry workers. Within the poultry workers, those who performed packing, sanitation, and chilling had a trend toward less CTS than those who performed tasks requiring more repetitive and strenuous hand movements.
Latino poultry processing workers have a high prevalence of CTS, which likely results from the repetitive and strenuous nature of the work.
This analysis described Latino migrant farmworkers' work safety climate and its association with musculoskeletal discomfort, working while injured or ill, and depressive symptoms.
Data were from a cross-sectional survey of 300 farmworkers conducted in North Carolina in 2009. Generalized estimating equations models were used to investigate the association of work safety climate with health and safety outcomes.
Farmworkers perceived their work safety climate to be poor. About 40% had elevated musculoskeletal discomfort, 5.0% had worked at least 1 day while injured or ill, and 27.9% had elevated depressive symptoms. The odds of elevated musculoskeletal discomfort were 12% lower and the odds of working while injured or ill were 15% lower with each 1-unit increase in the work safety climate. Work safety climate was not associated with depressive symptoms.
Work safety climate was important for agricultural workers. Poor work safety climate was associated with health outcomes (musculoskeletal discomfort) and safety (working while injured or ill). Interventions to improve work safety climate in agriculture are needed, with these interventions being directed to employers and workers.