C. Suzanne Lea

Characterization of Residential Pesticide Use and Chemical Formulations through Self-Report and Household Inventory: The Northern California Childhood Leukemia Study

Background: Home and garden pesticide use has been linked to cancer and other health outcomes in numerous epidemiological studies. Exposure has generally been self-reported, so the assessment is potentially limited by recall bias and lack of information on specific chemicals. Objectives: As part of an integrated assessment of residential pesticide exposure, we identified active ingredients and described patterns of storage and use. Methods: During a home interview of 500 residentially stable households enrolled in the Northern California Childhood Leukemia Study during 2001–2006, trained interviewers inventoried residential pesticide products and queried participants about their storage and use. U.S. Environmental Protection Agency registration numbers, recorded from pesticide product labels, and pesticide chemical codes were matched to public databases to obtain information on active ingredients and chemical class. Poisson regression was used to identify independent predictors of pesticide storage. Analyses were restricted to 259 participating control households. Results: Ninety-five percent (246 of 259) of the control households stored at least one pesticide product (median, 4). Indicators of higher sociodemographic status predicted more products in storage. We identified the most common characteristics: storage areas (garage, 40%; kitchen, 20%), pests treated (ants, 33%; weeds, 20%), pesticide types (insecticides, 46%; herbicides, 24%), chemical classes (pyrethroids, 77%; botanicals, 50%), active ingredients (pyrethrins, 43%) and synergists (piperonyl butoxide, 42%). Products could contain multiple active ingredients. Conclusions: Our data on specific active ingredients and patterns of storage and use will inform future etiologic analyses of residential pesticide exposures from self-reported data, particularly among households with young children.

Lessons learned from building a culture and infrastructure for continuous quality improvement at Cabarrus Health Alliance.

This case study describes a local public health agencys multiyear effort to establish an infrastructure and organizational culture for continuous quality improvement, using data from interviews with the agencys senior leaders, managers, and frontline staff. Lessons learned include the importance of setting stretch goals, engaging leaders at all levels of the organization, empowering frontline staff to make changes, providing quality improvement training for staff and leaders, starting with small projects first, spreading quality improvement efforts to involve all parts of the agency, and sustaining momentum by creating a supporting infrastructure for continuous quality improvement and continually initiating new projects.

Reliability of maternal-reports regarding the use of household pesticides: experience from a case-control study of childhood leukemia.

INTRODUCTION Self-reported household pesticide use has been associated with higher risk of childhood leukemia in a number of case-control studies. The aim of this study is to assess the reliability of self-reported household use of pesticides and potential differences in reliability by case-control status, and by socio-demographic characteristics. METHODS Analyses are based on a subset of the Northern California Childhood Leukemia Study population. Eligible households included those with children less than 8 years old who lived in the same residence since diagnosis (reference date for controls). The reliability was based on two repeated in-person interviews. Kappa, percent positive and negative agreements were used to assess reliability of responses to ever/never use of six pesticides categories. RESULTS Kappa statistics ranged from 0.31 to 0.61 (fair to substantial agreement), with 9 out of the 12 tests indicating moderate agreement. The percent positive agreement ranged from 46 to 80% and the percent negative agreement from 54 to 95%. Reliability for all pesticide types as assessed by the three reliability measures did not differ significantly for cases and controls as confirmed by bootstrap analysis. For most pesticide types, Kappa and percent positive agreement were higher for non-Hispanics than Hispanics and for households with higher income vs. lower income. CONCLUSIONS Reproducibility of maternal-reported pesticide use was moderate to high and was similar among cases and controls suggesting that differential recall is not likely to be a major source of bias.

Assessment of Sun Safety Behavior among Farmers Attending a Regional Farm Show in North Carolina

ABSTRACT Background: Due to the nature of working outdoors, many farmers experience high levels of exposure to ultraviolet radiation (UVR) whereby, increasing their risk for skin cancer. The primary goal of this study was to evaluate personal behavior and perception on sun protection among farmers attending a regional farm show in North Carolina. Methods: Farmers (n = 397) were asked to complete a self-administered questionnaire regarding behavior and importance of using personal sun protection (i.e., sunblock, etc.,) when working outdoors. Results: There were 285 (71.8%) male farmers and 79 (19.9%) female farmers with a mean age of 54 years. Overall, the majority of farmers recognized the importance of protecting themselves from the sun, however, actual personal behavior for using proper protection methods ranked low. Farmers with lighter, fairer skin tended to use more sun protection and ranked the importance of sun protection higher when compared to those with skin that was less likely to burn in the sun. Conclusion: The importance of personal sun protection should continue to be stressed to farmers at every available opportunity including farm shows, trainings and through health care providers.

“Fault-line of an Earthquake”: A Qualitative Examination of Barriers and Facilitators to Colorectal Cancer Screening in Rural, Eastern North Carolina

PURPOSE Colorectal cancer (CRC) is a leading cause of cancer mortality and disparately affects rural, low-income and minority individuals. Thus, to inform effective interventions and policies to increase screening rates and thus ameliorate CRC disparities, this studys purpose was to examine barriers and facilitators to CRC screening among low-income, rural eastern North Carolina residents. METHODS We conducted 4 focus group discussions in October and November 2011, among a convenience sample of eastern North Carolina residents (n = 45). The focus group discussion guide included open-ended questions about barriers and facilitators to CRC screening. Discussions were audio recorded and then transcribed verbatim. A codebook listing codes and operational definitions was developed by 2 research team members, who then iteratively and independently double-coded all transcripts. Nvivo (version 9, QSR International Pty Ltd, Doncaster, Victoria, Australia) was used to manage data. Themes were extracted based upon depth and frequency of mention. FINDINGS Major barriers to CRC screening included the high cost of tests and follow-up care, fear of the test itself (colonoscopy), fear of cancer diagnosis, and fear of burdening family members. Violation (among men) and embarrassment (among women) were also barriers. Facilitators included doctors recommendation, symptoms, support from family and friends, and the desire to live a long and healthy life. Intervention ideas included free tests with information and resources for follow-up care as needed. CONCLUSION Understanding barriers and facilitators to CRC screening can assist clinicians and public health practitioners in designing effective interventions to reduce CRC disparities.

Early evaluation results from a statewide quality improvement training program for local public health departments in North Carolina.

CONTEXT Many state and local public health agencies have developed accreditation systems and are utilizing quality improvement (QI) methods and tools to improve the public health infrastructure. Development of strategies to support and build the capacity of the public health workforce to apply QI can help advance these efforts. OBJECTIVE This article describes the adaptation and creation of a standardized QI training program for local health departments (LHDs), explores the effectiveness of the program in increasing the confidence of the LHD staff to apply QI methods and tools, and discusses lessons learned from the first cohort of the program. METHODS An existing program designed for health care professionals was pilot tested, adapted, and used in 8 LHDs. A formative evaluation of the new public health QI training program was conducted through a hybrid internal and external evaluation model. Pre/postsurveys were used to measure participant satisfaction and the capacity of LHD staff to conduct QI. RESULTS Staff from 8 LHDs successfully completed the program and 94% of participants reported that they were satisfied with the overall training program. Seventy percent of participants reported a higher perceived confidence in conducting a QI project, and all participants reported sharing QI tools and methods with their coworkers. CONCLUSION These findings suggest that QI training programs using methods and tools previously applied in health care and other industries can be successfully adapted to public health. Although additional studies are needed to validate the results, this training model can be used to inform future work in developing a standardized QI training program in public health.

Seasonal Influenza Vaccination Coverage Among Local Health Department Personnel in North Carolina, 2007–2008

BACKGROUND National estimates indicate that a low proportion of institutional and hospital-based healthcare workers obtain influenza vaccine. Information on seasonal influenza vaccination coverage in county-level public healthcare workers is lacking, including knowledge, attitudes, and perceptions regarding seasonal influenza vaccination. PURPOSE The purpose of this study was to investigate the percentage of employees receiving seasonal influenza vaccination, including perceptions and attitudes of employees of 17 health agencies in a 25-county region in eastern, rural North Carolina. METHODS Prior to the H1N1 pandemic, an 18-item voluntary, self-administered survey (pen-and-paper or web-based) was provided to 1653 employees of 15 local health departments and two health jurisdictions in 25 counties of eastern North Carolina in May 2008, obtaining vaccination information for 2007-2008 influenza season. Analysis was conducted in summer 2008 and October 2009. RESULTS A total of 1209 respondents completed the survey (73% response proportion). Seventy-two percent of valid survey respondents voluntarily received free influenza vaccine for the 2007-2008 season. Gender, ethnicity, and >or=10 years working in public health were significantly associated with obtaining vaccine. Using logistic regression, positive significant predictors were having a vaccination last year and perceived importance of vaccine. Cost to obtain vaccination was a deterrent. The most common reason stated was to protect people (66%), while the most common reason for not receiving the vaccine was belief that the vaccine can cause illness (19%). Almost 60% of employees reported support for a mandatory seasonal influenza vaccination program at their health department. CONCLUSIONS The percentage of county public health workers obtaining seasonal influenza vaccination is almost twice that of healthcare workers in other settings. This study provides evidence that efforts may be successful in increasing influenza vaccination coverage of healthcare workers.

Differences in reproductive risk factors for breast cancer in middle-aged women in Marin County, California and a sociodemographically similar area of Northern California

BackgroundThe Northern California county of Marin (MC) has historically had high breast cancer incidence rates. Because of MCs high socioeconomic status (SES) and racial homogeneity (non-Hispanic White), it has been difficult to assess whether these elevated rates result from a combination of established risk factors or other behavioral or environmental factors. This survey was designed to compare potential breast cancer risks and incidence rates for a sample of middle-aged MC women with those of a demographically similar population.MethodsA random sample of 1500 middle-aged female members of a large Northern California health plan, half from Marin County (MC) and half from a comparison area in East/Central Contra Costa County (ECCC), were mailed a survey covering family history, reproductive history, use of oral contraceptives (OC) and hormone replacement therapy (HRT), behavioral health risks, recency of breast screening, and demographic characteristics. Weighted data were used to compare prevalence of individual breast cancer risk factors and Gail scores. Age-adjusted cumulative breast cancer incidence rates (2000–2004) were also calculated for female health plan members aged 40–64 residing in the two geographic areas.ResultsSurvey response was 57.1% (n = 427) and 47.9% (n = 359) for MC and ECCC samples, respectively. Women in the two areas were similar in SES, race, obesity, exercise frequency, current smoking, ever use of OCs and HRT, age at onset of menarche, high mammography rates, family history of breast cancer, and Gail scores. However, MC women were significantly more likely than ECCC women to be former smokers (43.6% vs. 31.2%), have Ashkenazi Jewish heritage (12.8% vs. 7.1%), have no live births before age 30 (52.7% vs. 40.8%), and be nulliparous (29.2% vs. 15.4%), and less likely to never or rarely consume alcohol (34.4% vs. 41.9%). MC and ECCC women had comparable 2000–2004 invasive breast cancer incidence rates.ConclusionThe effects of reproductive risks factors, Ashkenazi Jewish heritage, smoking history, and alcohol consumption with regard to breast cancer risk in Marin County should be further evaluated. When possible, future comparisons of breast cancer incidence rates between regions should adjust for differences in income and education in addition to age and race/ethnicity, preferably by using a sociodemographically similar comparison group.

Using quality improvement to promote breast-feeding in a local health department.

In 2008, breast-feeding initiation and continuation rates in Beaufort County, North Carolina, were lower than statewide rates. A quality improvement (QI) project was initiated to increase breast-feeding rates by enhancing the overall environment that supports breast-feeding at the Beaufort County Health Department. This case study describes one of the first QI initiatives implemented through the North Carolina Center for Public Health Quality QI training program, conducted in 2009. The aim of this project was to improve the health and wellness of mothers and infants in Beaufort County by promoting breast-feeding among Beaufort County Health Department Women, Infants and Children (WIC) clients. Using QI tools, 4 new approaches to breast-feeding promotion were tested and implemented: creating a nurturing location to breast-feed while at the health department, actively telephoning new mothers to provide breast-feeding support, incentivizing adoption of educational messages by providing a breast-feeding tote bag, and promoting new WIC food packages. These enhancements involved staff in QI planning and implementation and correlated with improved breast-feeding initiation for WIC clients during the year following project completion.

Melanoma Incidence Rates in Active Duty Military Personnel Compared With a Population-Based Registry in the United States, 2000–2007

OBJECTIVES This study was conducted to investigate whether incidence rates of malignant cutaneous melanoma in U.S. Department of Defense active duty military personnel differed from rates in the U.S. general population between 2000 and 2007. METHODS The study population included active duty military personnel and the general population aged 18 to 56 years. Data were obtained from the U.S. Department of Defense medical data systems and from the Surveillance Epidemiology and End Results program. Melanoma risk was estimated by incidence rate ratios (IRRs). RESULTS Melanoma risk was higher among active duty personnel than the general population (IRR = 1.62, 95% confidence interval = 1.40-1.86). Incidence rates were higher for white military personnel than for white rates in general population (36.89 and 23.05 per 100,000 person-years, respectively). Rates were also increased for military men and women compared with SEER (men, 25.32 and 16.53 per 100,000; women, 30.00 and 17.55 per 100,000). Air Force service personnel had the highest rates and Army had the lowest. CONCLUSION Melanoma rates were marginally higher among active duty military personnel than the general population between 2000 and 2007.