Ethical issues in conducting migrant farmworker studies

Migrant farmworkers should be considered a vulnerable population because they work in a hazardous industry, are often members of an ethnic minority, have known difficulty in accessing health care, and are often of lower socioeconomic status. For these reasons, too, it is extremely important to conduct health-related research with this often-underserved group. However, because migrant farmworkers are vulnerable, investigators must be especially vigilant in protecting them from the potential harms of research and in ensuring that the special ethical issues that arise in research with this population are identified and addressed for every project. In response to the National Cancer Institute's concerns about the feasibility of conducting epidemiologic studies among migrant farmworkers, researchers undertook four feasibility studies near the Texas-Mexico border. Each study raised different, complex ethical questions that challenged the investigators, but whose resolution turned out to be crucial to the success of the studies.     

Charges for oral health care during a period of economic growth in the US: 1987-96

OBJECTIVES: This study aimed to provide estimates of amounts charged for dental care during 1996 for the US adult population and its major sociodemographic subgroups, and to evaluate whether charges had increased since 1987. METHODS: We used data from the 1996 Medical Expenditures Panel Survey and report results for 12,931 adults aged 19-64 years. For comparison with previously published charges, we converted 1987 charges to their 1996 "constant dollar" value to control for inflation. Data were analyzed using SUDAAN and the results can be generalized to the US adult population. RESULTS: In 1996, 43.7 percent (95% CI=42.7%, 44.6%) of the US population incurred dental care charges, which did not differ significantly from the 1987 estimate of 44.5 percent. In 1996, mean per capita charge for dental care was 182 dollars (95% CI=171 dollars, 192 dollars), which did not differ significantly from the inflation-adjusted 1987 estimate of 174 dollars. The average charge per patient who incurred charges in 1996 was 416 dollars (95% CI=394 dollars, 438 dollars), which was only 7 percent greater than the inflation-adjusted 1987 estimate of 389 dollars (P=.08). Sociodemographic variations were observed in per capita charges, but were less apparent in mean charge per patient who incurred charges. CONCLUSIONS: During a period when economic growth and other market forces were expected to increase delivery of dental services, there was little or no change in percentage of US adults incurring charges or in mean per capita charges. The booming US economy did not raise dental charges significantly and did not increase utilization of dental care services.     

Promoting HIV Testing Among Never-Tested Hispanic Men: A Doctor's Recommendation May Suffice

This study examined factors associated with HIV testing intentions among a community sample of 255 never-tested Hispanic men. It compared (1) men who intended to test in the next 6 months with those who did not and (2) men who intended to test only on the day of the interview with those who intended to test in the next 6 months. Eighty-four percent of men had never been offered testing. Yet, 86% would accept testing if recommended by their doctor. The strongest multivariate predictor of testing intention was willingness to accept a physician-endorsed test. Almost 49% of men who intended to test in the next 6 months would only do so if the test were offered on the interview day. These findings highlight the importance of encouraging physicians, particularly in high-prevalence areas, to routinely recommend testing. They also suggest that for some men, there is a window of opportunity for testing that does not endure.     

Cervical cancer among Hispanic women: assessing the impact on farmworkers

The purpose of this paper was to review the literature on Hispanic populations to outline: 1) demographics; 2) general health status; 3) cervical cancer incidence and mortality; 4) Pap smear screening rates; and 5) barriers to preventive care services. The methods: MEDLINE, Med66, Med75, and Med85 files, from 1966 to 1999, were searched for key words Hispanic health, cervical cancer and Hispanics, cervical cancer and Mexico, migrants and health, agricultural occupational health, farmworkers and cancer, and farmworker health. AGRICOLA (1982–98) was searched for key words farmworker health, agricultural workers and health, and agriculture and cancer. The results show that Hispanic immigrant women may have cervical cancer incidence rates ranging between the California rates for 1991–93 (19.8/100,000) and for Mexico in 1990 (115–220 per 100,000). Mortality rates for the same periods were 3.9/100,000 and 16.11/100,000 respectively. While survey results report Hispanic Pap smear rates above 70%, these surveys count urban women who do not share the barriers to care experienced by poor rural Hispanics. Since validated self-reports of survey responses are 20–50% lower than reported lower rates and Pap smear screening persist in Hispanic Pap evaluations and are reflected in higher morbidity and mortality from cervical cancer. That targeted community interventions have been successful in raising Pap smear rates among poor Spanish-speaking women. Such interventions should be a priority for preventive health care policy and practice.     

Knowledge, Skills, and Behavior Improvements on Peer Educators and Low-Income Hispanic Participants After a Stage of Change-Based Bilingual Nutrition Education Program

A nutrition education program, entitled La Cocina Saludable, was designed according to the Stage of Change Model and implemented in ten southern Colorado counties. The objectives were to improve the nutrition related knowledge, skills, and behaviors that lead to healthy lifestyles in a low-income Hispanic population. The content of the program included nutrition information designed to help mothers of preschool children provide for their children's nutritional needs. Previous studies suggest that low-income Hispanics often demonstrate low intakes of vitamins A and C, calcium, iron, and protein, and high rates of diabetes, obesity, and infections. Additionally, this population presents many obstacles for nutrition educators including limited resources, child care, transportation, time, language, culture, literacy, health beliefs, and, in some cases, the transient nature of the population. The program attempted to overcome these barriers by incorporating a flexible program format carried out by abuela (Hispanic grandmother) educators using the processes described in the Stage of Change Model. The program was evaluated using a knowledge, skills and behavior pre-test, post-test, and six-month follow-up survey on both the abuela educators as well as the actual class participants. Results of the peer education training sessions suggest that this type of training program can be effective in increasing the knowledge, skills, and behavior of peer educators as well as reduce need for retraining for educators who continuously teach classes. Additionally, the results suggest that this type of program can be effective in changing selected nutrition related knowledge, skills, and behaviors leading to healthy lifestyles for low-income Hispanic mothers of preschool children.     

Cladistic Analysis of Human Apolipoprotein A4 Polymorphisms in Relation to Quantitative Plasma Lipid Risk Factors of Coronary Heart Disease

Genetic variation in several genes involved in lipid metabolism is known to affect population variation in quantitative lipid risk factor profiles for coronary heart disease (CHD). The apolipoprotein A‐IV gene (APOA4) is one such candidate gene. We genotyped five polymorphisms in the APOA4 gene (codon 127, codon 130, codon347, codon 360 and 3’ VNTR) and investigated their impact on plasma lipid trait levels in three populations comprising 604 U.S. non‐Hispanic Whites (NHWs), 408 U.S. Hispanics and 708 Nigerian Blacks. Cladistic analysis was carried out to identify 5‐site haplotypes that were associated with significant phenotypic differences in each population. The distribution of APOA4 genotypes was significantly different between ethnic groups. The Africans were monomorphic for two of the five sites (codons 130 and 360), but possess a unique 12 bp insertion that was not observed in NHWs and Hispanics. Due to linkage disequilibrium between the sites, only 6 haplotypes were observed in NHWs and Hispanics, and 4 in Africans. Several gender‐and ethnic‐specific associations between genotypes and plasma lipid traits were observed when single sites were used. Several haplotypes were identified by cladistic analysis that may carry functional mutations that affect plasma lipid trait levels.     

COVID-19 among African Americans and Hispanics: Does gastrointestinal symptoms impact the outcome?

BACKGROUNDThe coronavirus disease 2019 (COVID-19) disproportionately affected African Americans (AA) and Hispanics (HSP). AIMTo analyze the significant effectors of outcome in African American patient population and make special emphasis on gastrointestinal (GI) symptoms, laboratory values and comorbiditiesMETHODSWe retrospectively evaluated the medical records of 386 COVID-19 positive patients admitted at Howard University Hospital between March and May 2020. We assessed the symptoms, including the GI manifestations, comorbidities, and mortality, using logistic regression analysis.RESULTSOf these 386 COVID-19 positive patients, 257 (63.7%) were AAs, 102 (25.3%) HSP, and 26 (6.45%) Whites. There were 257 (63.7%) AA, 102 (25.3%) HSP, 26 (6.45%) Whites. The mean age was 55.6 years (SD = 18.5). However, the mean age of HSP was the lowest (43.7 years vs 61.2 for Whites vs 60 for AAs). The mortality rate was highest among the AAs (20.6%) and lowest among HSP (6.9%). Patients with shortness of breath (SOB) (OR2 = 3.64, CI = 1.73-7.65) and elevated AST (OR2 = 8.01, CI = 3.79-16.9) elevated Procalcitonin (OR2 = 8.27, CI = 3.95-17.3), AST (OR2 = 8.01, CI = 3.79-16.9), ferritin (OR2 = 2.69, CI = 1.24-5.82), and Lymphopenia (OR2 = 2.77, CI = 1.41-5.45) had a high mortality rate. Cough and fever were common but unrelated to the outcome. Hypertension and diabetes mellitus were the most common comorbidities. Glucocorticoid treatment was associated with higher mortality (OR2 = 5.40, CI = 2.72-10.7). Diarrhea was prevalent (18.8%), and GI symptoms did not affect the outcome.CONCLUSIONAfrican Americans in our study had the highest mortality as they consisted of an older population and comorbidities. Age is the most important factor along with SOB in determining the mortality rate. Overall, elevated liver enzymes, ferritin, procalcitonin and C-reactive protein were associated with poor prognosis. GI symptoms did not affect the outcome. Glucocorticoids should be used judiciously, considering the poor outcomes associated with it. Attention should also be paid to monitor liver function during COVID-19, especially in AA and HSP patients with higher disease severity     

Diagnostic Accuracy of Spanish Language Depression-Screening Instruments

PURPOSE To make decisions about implementing systematic depression screening, primary care physicians who serve Spanish-speaking populations need to know whether Spanish language depression-screening instruments are accurate. We aimed to review systematically the evidence regarding diagnostic accuracy of depression-screening instruments in Spanish-speaking primary care populations.METHODS We searched PubMed, PsycINFO, CINAHL, EMBASE, and Cochrane Libraries from inception to May 28, 2008, for studies examining the diagnostic accuracy of Spanish language depression case-finding instrument(s) administered to primary-care outpatients. Two authors independently assessed studies for inclusion and quality.RESULTS Twelve studies met inclusion criteria. In general primary care screening, the Spanish language version of the Center for Epidemiologic Studies-Depression scale (CES-D) had sensitivities ranging from 76% to 92% and specificities ranging from 70% to 74%. We found no US study reporting the accuracy of the Primary Care Evaluation of Mental Disorders (PRIME-MD-9) or the Patient Health Questionnaire (PHQ-9) depression module in Spanish-speakers. One fair-quality European study and 1 poor-quality study conducted in Honduras found the 9-item PRIME-MD had sensitivities ranging from 72% to 77% and specificities ranging from 86% to 100%. The 2-item PRIME-MD was 92% sensitive, but only 44% specific for depression in 1 US study. In geriatric outpatients, the 15-item Spanish language version of the Geriatric Depression Scale (GDS) had sensitivities ranging from 76% to 82%, and specificities ranging from 64% to 98%. In postpartum women, the Spanish language version of the Edinburgh Postnatal Depression Scale (EPDS) was 72% to 89% sensitive and 86% to 95% specific for major depression (2 non-US studies). The Spanish language version of the Postpartum Depression Screening Scale (PDSS) was 78% sensitive and 85% specific for combined major/minor depression (1 US study).CONCLUSIONS For depression screening in Spanish-speaking outpatients, fair evidence supports the diagnostic accuracy of the CES-D and PRIME-MD-9 in general primary care, the GDS-15-Spanish for geriatric patients, and the Spanish language versions of the EPDS or PDSS for postpartum patients. The ultrashort 2-item version of PRIME-MD may lack specificity in US Spanish-speakers.     

Elicitation of Salient Beliefs Related to Drug Preparation Practices Among Injection Drug Users in Puerto Rico

Even when IDUs use their own syringes, the common use of drug preparation materials can expose them to blood-borne pathogens. Notwithstanding the accumulated evidence about the riskiness of drug preparation practices (DPPs), the factors that lead IDUs to engage in DPPs have remained understudied. We conducted 80 semi-structured interviews to elicit salient beliefs about engaging in low-risk DPPs. Data were content analyzed for consequences, normative influences, and barriers. For the most part respondents described positive consequences of engaging in low-risk DPPs. The majority of respondents mentioned IDU peers as a major source of pressure to engage in high-risk DPPs. Lack of access to clean materials and the need to carry materials on oneself were the most salient barriers elicited. The results suggest that preventive interventions need to address the preference for re-using filters, help develop skills to fend off pressures from peers, and increase the accessibility of materials in ways that do not require IDUs to carry additional items.     

Genetic admixture and asthma-related phenotypes in Mexican American and Puerto Rican asthmatics

Genetic association studies in admixed populations may be biased if individual ancestry varies within the population and the phenotype of interest is associated with ancestry. However, recently admixed populations also offer potential benefits in association studies since markers informative for ancestry may be in linkage disequilibrium across large distances. In particular, the enhanced LD in admixed populations may be used to identify alleles that underlie a genetically determined difference in a phenotype between two ancestral populations. Asthma is known to have different prevalence and severity among ancestrally distinct populations. We investigated several asthma-related phenotypes in two ancestrally admixed populations: Mexican Americans and Puerto Ricans. We used ancestry informative markers to estimate the individual ancestry of 181 Mexican American asthmatics and 181 Puerto Rican asthmatics and tested whether individual ancestry is associated with any of these phenotypes independently of known environmental factors. We found an association between higher European ancestry and more severe asthma as measured by both forced expiratory volume at 1 second (r=-0.21, p=0.005) and by a clinical assessment of severity among Mexican Americans (OR: 1.55; 95% CI 1.25 to 1.93). We found no significant associations between ancestry and severity or drug responsiveness among Puerto Ricans. These results suggest that asthma severity may be influenced by genetic factors differentiating Europeans and Native Americans in Mexican Americans, although differing results for Puerto Ricans require further investigation.