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Prevalence And Influence On Quality Of Life Of Symptoms Caused By Inhaled Odors, Chemicals And Irritants: A Comparis on Between Hispanics And Americans by Carmen Perez A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in Public Health Department of Environmenta l and Occupational Health College of Public Health University of South Florida Major Professor: Stuart Brooks, M.D. Thomas Truncale, D.O. Chu-Hsiang Chang, Ph.D. Date of approval: April 10, 2009 Keywords: allergy, ethnicity, expo sure, questionnaire, sensitivity Copyright 2009, Carmen Perez
Dedication To my loving husband and wonderful son for their love and support in my pursuit of professional enrichment.
Acknowledgements My gratitude and foremost admiration to Dr Stuart M. Brooks for giving me the opportunity to do this research under his guidance, for his moral support, and for providing me with a thorough education which demonstrates his devotion to the be tterment of public health and all human kind. My deepest gratitude to Dr. Thomas Tr uncale for his advice and training in the fundamentals of research met hodology, and to Dr. Eve Hanna for sharing her experiences with extraordinary kindness and grace. Special gratitude to Tabitha Raj for goi ng beyond the requirements of her duties to helping me with the collection of questionnaires and her moral support. Thank you to Dr. Daisy Chang for assisting me with data analysis and methodology recommendations. Thank you to Dr. Aurora Sanchez-Anguiano for her recommendations and to Ariadne Miranda from the USF English Langua ge Institute for helping me with the translation of questionnaires. Many thanks to my professors Peter Re ntos, Steve Mlynarek, Yehia Hammad and Heather Stockwell, for their dedicated contri bution to my development in the field of Occupational and Envi ronmental Health.
i Table of Contents List of Tables . ii List of Figures iii Abstract .................................. iv Chapter I Introduction . ... 1 Chapter II Hypothesis and Specific Objectives .. 9 Chapter III Methods .. .10 Study design and population ..10 Definition of variables ...11 Data Collection . 15 Statistical Analysis 15 Chapter IV Results . ... 16 Socio-demographic characteristics .. . 16 Medical history and smoking habit 18 Sensitivity and reaction to specific irritants in the study population.... .... 19 Symptoms and Quality of Life due to exposure to irritants .. 22 Sensitivity and reaction to sp ecific irritants by ethnicity ... 23 Symptoms and Quality of Life due to exposure to irritants by ethnicity... 24 Ethnical differences on self-reported symptoms and Quality of Life controlling health and sociodemographic variables . 26 Chapter V Discussion .. . 44 Theoretical and research implication .52 Limitations .53 List of References .. ........55 Appendices 58 Appendix A: Cover Letter 59 Appendix B: Additional Questionnaire 60 Appendix C: Demographic and Medical Information Questionnaire ... 61 Appendix D: Chemical, Odorant and Irritant Sensitivity Questionnaire .. 62 Appendix E: Cover Letter and Questionna ires translated to Spanish .. .64
ii List of Tables Table 1: Demographic characteri stics of the st udy population ..18 Table 2: Medical history of the study population ... ...19 Table 3: Sensitivity when exposure to i nhaled chemicals, irritants, odors and strong fragrances and reacti on to specific irritants . ...21 Table 4: Symptoms and quality of life due to exposure to cigarette smoke, automobile exhaust, strong smells, perfumes or fresh paint vapors .. 23 Table 5: Sensitivity with exposure to i nhaled chemicals, irritants, odors and strong fragrances and reaction to specific irritants by ethnicity . ...24 Table 6: Symptoms and quality of life w ith exposure to cigarette smoke, automobile exhaust, strong smells, fragrances or fresh paint vapors by ethnicity ...25 Table 7: Sensitivity with exposure to inha led chemicals, irritants, odors and strong fragrances and reaction to specific irrita nts by ethnicity and history of Allergy ...31 Table 8: Symptoms and quality of life w ith exposure to cigarette smoke, automobile exhaust, strong smells, fragrances or fres h pain vapors by ethnicity and history of Allergy ...37 Table 9: Lower Respiratory symptoms by ethnicity and current smoker status 38 Table 10: Neuro-psychological Sy mptoms by ethnicity and age ..41 Table 11: Quality of life by ethnicity and use of steroids or antibiotics within the past 4 weeks ... ... ..42 Table 12: Quality of life by ethnicity and gender ..43
iii List of Figures Figure 1: Distribution of the population by gender and ethnicity ..17 Figure 2: Distribution of the population by age and ethnicity ...17 Figure 3: Sensitivity to inhaled chemicals, ir ritants, odors and fragrances by ethnicity...................................................................................................................... ........27 Figure 4: Sensitivity to inhaled chemicals, ir ritants, odors and fragrances by ethnicity and hist ory of Allergy . 28 Figure 5: Reaction to cigarette smoke by ethnicity 29 Figure 6: Reaction to cigarette smoke by ethnicity and history of Allergy ...30 Figure 7: Non-Specific Symptoms due to exposures by ethnicity .33 Figure 8: Non-Specific Symptoms due to expos ures by ethnicity and history of Allergy ...34 Figure 9: Quality of Life due to exposures by ethnicity 35 Figure 10: Quality of Life due to exposu res by ethnicity and hi story of Allergy ..36 Figure 11: Lower Respiratory symptoms due to exposures by ethnicity ...39 Figure 12: Lower Respiratory symptoms due to exposures by ethnicity and current smoker status .40 Figure 13: Quality of Life due to expo sures by ethnicity and steroids or antibiotics use . 42
iv Prevalence and Influence on Quality of Life of Symptoms Caused by Inhaled Odors, Chemicals and Irritants: A Comparison between Hispanics and Americans. Carmen Perez ABSTRACT Efforts to estimate the population prevalen ce of chemical sensitivities have been limited and have yielded different estimates of the prevalence of affected individuals. Researchers recognize that people differ in their biological susceptibility to environmental contaminants as well as th e amount of contaminant to which they are potentially exposed. Lack of information on the population prevalence of people, who report sensitivity to a chemical or many chemicals, as well as variables associated, has been recognized in previous studies (Kreutzer et al ., 1999). In a more recent report, Berg et al., in 2007 reported the prevalence and consequences related to inhalation of chemicals in a Danish population. They conclude d that the symptoms related to inhalation of airborne chemicals were common, especially among women. A small part of hat population reported that these symptoms affected social life or occ upational conditions. Details in prevalence on severity of sy mptoms caused by inhaled odors, chemicals and irritants have not been investigat ed comparing populations based on ethnical differences. These differences could influe nce how individuals report their symptoms. This study evaluated the differences between Americans and Hispanic s in sensitivity and symptoms related to inhalation of strong odors, chemical and irritants. We also evaluated
v the differences between both et hnic groups on quality of lif e due to these symptoms. A cross-sectional descriptive study was conducted between December 2008 and March 2009. A self-administered questionnaire was dist ributed to a total of 290 adults and 205 were selected for the analysis. American a nd Hispanic individuals of 16 years old or more were included. The responses were cross-tabulated and comparisons between means were performed using t-test an d ANOVA. 29.8% of study population reported being more sensitive than the average pers on and women reported more than men (75%). These findings were consistent with previous reported in th e literature. The reaction more frequent reported was to cigarette smoke (60 %). Statistically significant differences were identified between Americans and Hispanic s regarding to sensitivity to chemicals, irritants, odors or strong fr agrances and reaction to ciga rette smoke when history of Allergy is present. Significant differences be tween both ethnic groups were detected with Lower Respiratory, Neuro-psychological a nd Non-specific symptoms; and Quality of life. These differences were disclosed when history of Allergy, smoking habit, used steroids or antibiotics within the last 4 w eeks, and age were considered. Americans reported being more sensitive with exposure to recognized everyday ir ritants, react more to cigarette smoke and reported more Non-specific symptoms than Hispanics. Hispanic smokers tend to report Lower Respiratory symptoms more than the Americans. Hispanics between 50 to 59 years old reported more Neuro-psychological symptoms than Americans. Quality of life was more affect ed among Americans if they are exposed to common irritants, when Allergy history a nd use of steroids or antibiotics were considered.
1 Chapter I Introduction Some chemicals, routinely encountered in everyday life, produce strong odors and/or fumes that can further irritate alre ady inflamed airways. They are sometimes referred to as irritants. Perfumes, hairsprays cleaning solutions, air fresheners, cooking fumes, paints and varnishes are some of them. People frequently complain that perfumes and fragrance products cause or contribute to health problems such as asthma, migraines, and upper re spiratory irritation. Is this simply a reaction to the odor of th ese products or is it a serious concern? It is well known that during pregnanc y many odors that were perceived as pleasant or neutral before will cause nausea. After pregnancy the aversion to these odors usually disappears. When someone is ill, they are much more sensitive to odors. Again when the illness is over this sensitivity usua lly goes away. In both examples we have a physical change. Individual and genetic fact ors also play an important role in sensitivity to chemicals (Dalton, 2003). Just as some people can tolerate more s un than others, some people can tolerate more chemical exposure than others. Individual body chemistry varies and so does tolerance to chemicals. Indi vidual genetic susceptib ilities are based on
2 differences in major histocompatibility complex, toxin metabolism, lifestyles, and exposure rates. As a consequence individuals will react differently to the same chemicals (Gebbers, 2001). If this statement is true, ethnic differences woul d be one determining factor in the way people respond to exposure to chemicals. Each ethnic group has its own lifestyle that characterizes a nd encompasses a range of exposures. This makes them more tolerable to those exposures, therefore, comp lain less about them. For example, Japanese believe that fragrance calms the spirit. They have created an ol factory cultural of producing incense. They like to burn incense or fragrant woods in their homes before guests arrive. This would be less tolerabl e by people from other cultures. Culturalspecific experience can evoke different patterns of cognitive and emotional experience of an odor, and play a role in ones odor perception. There is evidence for ethnical differences in sensitivity and prefer ence for odors (Dalton & Beauchamp, 1999). It often takes repeated exposures in orde r for sensitivities to develop. It may seem that things that have been tolerated for years suddenly causes problems. Often sensitivities develop takes l ong time before they are recogni zed. It is often difficult to pinpoint the cause of symptoms such as sinus problems, skin irritations, and triggers for asthma. This is especially true when the tri ggering substance is one that is common in the environment. For the person who has asthma, migraine s, or serious health problems from exposure to common fragrance materials, it is very difficult to function in public settings. This makes it very difficult to work, shop for groceries, and other necessary activities. For those with less serious health problem s, such as sinus congestion and allergy symptoms such as runny noses and watering eyes, functioning is possible, but difficult.
3 Health and productivity can be seriously im pacted. Costs of upper respiratory illnesses are high, both in terms of medical trea tment and lost productivity at work. Community residents, workers and patients frequently report physical symptoms in relationship to environmental odors In 2001, Shusterman utilized three case studies in which an individual (or multiple individuals in a community) reported odor-associated physical symptoms. He made an analysis based upon the formal toxicological properties of the odorant(s) involved. He based this discussion in that environmental odors may play either a central or bystander role in the genesis of acute air pollution-related symptoms. Finally, he concluded that an important first step in analyzing such situations is to catalog the chemical agent(s) involved and to consider its relative odorant and irritant potencies. When potent odorants al one are involved in the exposure, or when the toxicology of copollutants is insufficient to explain observed symptoms, it may be necessary to invoke notoxicological explanations for odor-related symptoms. Some of these explanations involve attitudinal and/or behavioral responses to odors (Shusterman, 2001). The experimental data on the eff ect of unpleasant odors on human health reviewed in a question-and-answer format suggests, according to a review of recent studies done by Schiffman, that the main complaints of health symptoms from odors are eye, nose, and throat irritation, headache, and drowsiness. Persons who report symptoms from odors generally find problems with a broad array of compounds. A study was conducted in which subjects were again aske d how sensitive they were to odors. Then they were asked to fill out a single page Odor Questionnaire that did not mention the environment or length of exposure. Again, the sensitive subjects rated many items as problematic. However, the less-sensitive group rated only a few items as problematic
4 (mainly cigarette, cigar, and pipe smoke, a mmonia, and diesel exhaust). No more than 32% of the less-sensitive i ndividuals reported a problem with any item. This finding illustrated that the responses to surveys a bout odors can be affected by the perceived purpose of the questionnaire as well as th e duration of exposure (Schiffman, 1998). There are many factors that determine wh at will be tolerated without adverse effects and what will not. Those tolerances will vary from individual to individual. There may be variations in tolerance in the same individual depending on other factors involved. A healthy person can tolerate much more exposure than someone that is in poor health. Even a healthy person is more at ri sk when he or she is tired or stressed. Age also affects tolerance. The very young a nd the very old are more at risk. The young because many of the systems of the body are stil l developing and in the elderly health is often compromised. Children may be more su sceptible to the effects of fragrances because of their smaller size, their higher respiratory rate, an d their thinner skin. Skin in the elderly is usually thinner because of th e loss of the fat layer beneath the skin, so substances are more easily absorbed through the skin. Women are usually more prone to problem s from fragranced products for various reasons. When compared to men, women are usually smaller in size. This means the same exposure would be a higher dose for women. Women have also a higher ratio of body fat than men. Many chemicals are stored in fat tissue. A substance stored in the fat tissue can remain in the body for a long time. Also women are generally exposed to fragranced products more than men. Most household products are fragranced. The fragrance materials are inhaled and they are absorbed through the skin. Along with this, women's personal care products are usually more perfumed than men's, although this
5 trend is quickly changing. Several studies ha ve reported the high incidence of chemical sensitivity among women (Bell, 1993; Be rg, 2008; Joffres, 2001; Johansson, 2005; Kreutzer, 1999; & Meggs, 1996). Persons who are depressed may be more likely to make complaints about unpleasant odors. Doty et al reported that persons who clai m that odors bother them had higher scores on the Beck Depressi on scale than control subjects (Doty et al., 1988). Studies evaluating simultaneously chemical sensitivity to irritants and allergy in the general population have re ported equivalent prevalen ce in both. Meggs et al., for example, found that both conditions presen t simultaneously were reported by 16.9% of the population, chemical sensitivity only by 18.2%, and allergy without chemical sensitivity by 16.0%. Based in these findi ngs, they supported that the scientific investigation of chemical sensitivity is justified (Meggs et al., 1996). Lack of information on the population prev alence of people w ho report sensitivity to chemicals, as well as demographic or other variables associ ated was recognized by Kreutzer et al. in 1999. They conducted a popula tion based survey in California, and the report was published in 1999. They found th at the ethnic groups studied (including Hispanics, 23.8%) had similar rates of doc tor-diagnosed and perceived sensitivity to chemicals. However, later in the report, it was stated that Hispanic ethnicity was associated with physician-diagnosed multiple chemical sensitivity (OR 1.82). Based in these results of almost twice increased risk among Hispanics, it makes sense to provide additional test of these findings and look for possible differences among Hispanics and Americans in a sample in which both groups are equally represented. No other previous study has mentioned this distinction among Hisp anics and Americans. Because of this, it
6 is imperative to support the credibility of these findings, through population samples based studies. Even more in communities wher e this ethnic group contri bute is prevalent. Although traditionally, it has been consider ed susceptible groups that include children, the elderly, and those with preexis ting disease; the rese arch has focused on evaluating the effects of socioeconomic status race, ethnicity, gender, and other factors that may contribute to incr eased susceptibility. Researcher s recognize that people differ in their biologic susceptibility to environm ental contaminants. Furthermore, people also differ in the amount of contaminant to whic h they are potentially exposed. Despite recognition of these findings, available technol ogy has limited the abil ity of researchers to evaluate the biological factors that ma ke some people more vulnerable than others. Fortunately, recent advances in the ability to assess biological factors that influence risk have been made. We can now look at genetic fact ors, as well as the social and behavioral factors, that make people more vulnerable. Several studies indica te that age and preexisting disease play a major role in susceptibi lity to the adverse e ffects of air pollution. Race has also been investigated as a po ssibly influential factor on heightened susceptibility, especially among those with pr eexisting disease (Ber g, 2008; Fruin, 2003; & Meggs, 1996). In a recent study, Berg et al. reported the prevalence and consequences related to inhalation of chemicals in a Danish popul ation. They concluded that the symptoms related to inhalation of ai rborne chemicals were comm on, especially among women. A small percentage of participants reported th at these symptoms affected social life or occupational conditions (Berg et al., 2008).
7 Efforts to estimate the population prevalen ce of chemical sensitivities have been limited and have yielded different estimates of the prevalence of affected individuals (Berg, 2008; Caress, 2003; Johansso n, 2005; Meggs, 1996; & Steinemann, 2001). Details in prevalence on severity of sy mptoms caused by inhaled odors, chemicals and irritants have not been investigated co mparing specific populations based on ethnical differences. Most of the previous studies ha ve evaluated the differe nt races or ethnic groups among other socio-demographic variables. They agree that reports of sensitivity to chemicals are distributed homogeneously across racial/ethnic categories but they have not done in-depth analysis that allow identify possible ethnic dispari ties. (Caress, 2003; Kreutzer, 1999; Meggs, 1996; & Steinemann, 2001). The U.S. Office of Management and B udget currently defines "Hispanic or Latino" as "a person of Mexican, Puerto Ri can, Cuban, South or Ce ntral American, or other Spanish culture or origi n, regardless of race. American is a citizen of or from the United States. Based on these definitions we established our own definitions of ethnicity based on where the parents (both) were bor n. We chose not to study individuals from different ethnicities independen tly if she or he reported that she/he was born in United States. Hispanic ethnicity is widely distributed across seve ral states in Unites States, especially in Florida. This ethnic group is intermixing with other ones, and because of this; it is difficult sometimes identify one i ndividual in one category or other. Exact definition for our study is gi ven in the Method section. Our study has the purpose of identifying possible ethnic differences between the major groups of the population of our communit y. Further research is required to fully
8 assess the health impact of odors, chemicals a nd irritants across specif ic ethic groups with particular exposures. Based on the results from the Californias study we could think about existing differences between Hispanic s and Americans in our community in the way they report their symptoms. The minorities have different lifestyles or perform work differently from the majorities. They are usually exposed to different environmental issues in the workplaces with more exposures This makes sense thinking about different patterns of complaints or more tolera nce with exposure to irritants. The results obtained could contribute to motivate re searchers interest and contribute to the development of exposure guidelines for occupational and residential environment.
9 Chapter II Hypothesis and Speci fic Objectives Hypothesis: The prevalence and influence on quality of life of physical and psychological symptoms reported due to exposure to inha led odors, chemicals and irritants differ between Hispanics and Americans. Specific Objectives: 1. Evaluate the prevalence of symptoms re ported due to exposure to inhaled odors, chemical and irritants, through socio-de mographic and health variables, to identify differences between Hispanics and Americans. 2. Determine and contrast the variations on quality of life due to symptoms reported from exposure to inhaled odors, chemical s and irritants of both ethnic groups.
10 Chapter III Methods Study design and population A cross-sectional descriptive study wa s conducted between December 2008 and March 2009. During this 4 months period, a self -administered questionn aire, created in a previous study (Williamson, 2007) to determine the frequency and severity of symptoms caused by inhaled odors, chemicals and irr itants was distributed to adults. They voluntarily agreed to particip ate in the investigation. The total population part taken in the study was recruited in this period of time. The following criteria were considered to exclude subjects from the analysis: age le ss than 16 years and ethnicity other than American and Hispanic. The original questionnaire on self-reported symptoms related to inhalation of odors, chemicals and irritants, with 59 separa te items, consists of two sections. The first section included demographic, personal and health information (Appendix B). The second section contains questions regarding sensitivity to exposures from inhaled odors, chemicals, and irritants; as well as qual ity of life (Appendix C). Additional questions about socio-demographic information with 6 items were added in a separate sheet (Appendix D). The entire que stionnaire takes about 15 minutes to complete. The
11 questionnaire has a cover letter to inform the participants about the research project and decision to complete the survey (Appendix A). The socio-demographic information consis ted of gender, age, ethnicity, if the individual and his or her pa rents were born in United Stat es, information on educational level, and work location if employed was r ecorded. Representative items in personal and health information were answered as ye s or no. These items included smoking habits, pregnancy status in women, history of: alle rgies, respiratory sy mptoms or diseases, psychiatric disorder, other specific organs/s ystems symptoms or diseases; and if the individual used antihistamin es, steroids, antibiotics or heart medications. Questions regarding the sensitivity to inhaled odors, chemicals and irritants were based on symptoms and signs experienced by the individual as well as their interaction with social life when are exposed to cigarette smoke, au tomobile exhaust, strong smells, cologne, perfumes, scented candles and fresh paint vapors or fumes. The answers to sensitivity and quality of life questions were based on their experiences in the present and over the past year. The questionnaire format facilitated th e participants rating of their likelihood of agreement with the answers. Personally identifiable information was excluded. The questionnaires were translated to Spanis h and were available in both languages. Definition of variables Ethnicity : defined as identity with a particular national or cultural group and observance of that group's customs, beliefs, and language. This vari able was classified, on the investigators interest, as: American: individual from any race born in the United States, and descent from American parents born in U.S.
12 Hispanic: individual born in Centra l, South America or Caribbean Isles or born in the U.S as first generation descendents from parents born in these geographic areas, and Spanish speaking, regardless of race. This cat egory included individuals from: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Ri ca, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Uruguay, Venezuela, and Puerto Rico. In the questionnaire, the individuals rega rded themselves within the ethnicity categories. During the data processing, the inve stigator assigned each participant within the adequate category, depending on the answer s to the questions about where the parents were born, and based on previous defi nition of American or Hispanic. In the analysis the individuals were divide d into five age groups in age ranges of 10 years with the youngest being under 30 years of age and the oldest being over 59 years of age. Educational level was evaluated as an ordinal vari able with 4 categories: primary or elementary, high school, college or university, and graduate level. Workplace location was divided into five differe nt categories, based on possible common exposures to airborne odor and irritants in each category. For example, one category was indoor office where workers are more exposed to cigarette smoke, cologne, perfumes and scented candles. The other catego ries were enclosed vehicle, indoor plant or industry, outdoor, other location and unemployed. Th e individuals allocated themselves in a category based on if they st aying in that location during 6 hours or more. Health variables were defined from pe rsonal information of medical history included in the questionnaire and were categor ized according to Yes or No answers.
13 These dichotomous variables were grouped dur ing the data processing based on specific organ or system involved in the disease. This classification facilita ted the analysis when medical history was considere d. The health variables were: Allergy history: This variable consiste d on if the individual has history of allergy, hay fever, seasonal allergies, allergic rhinitis eczema, hives or use of antihistamines medications. Respiratory problems : If the individual reported hi story of respiratory problems, abnormal sense of smell, Asthma or daily cough. Non-respiratory problems: If the individual has hist ory of Hepatitis, Cirrhosis, Renal Failure, Arthritis or use heart medications. Neuro-psychiatric disorder: If the individual has hist ory of neurologic disorder, psychiatric disorder or use anti-depressant medications. Physician diagnosis: If the individual has been diagnosed by a physician with Fibromyalgia, Chronic Fatigue Syndrome or Multiple Chemical Sensitivity. Smoking habit: This individual characteristic was analyzed in two different variables, if the person is a current smoker and if has sm oked in the last 10 years. Pregnancy status: If the woman included in the study is pregnant. Use of steroids or antibiotics: If the individual has used at least one of these two medications within the past 4 weeks. We considered exposure to inhaled odors, chemicals and irritants when the individual was exposed to cigarette smoke, automobile exhaust, strong smells, cologne, perfumes or scented candles, and fresh pain t vapors or fumes. The reaction to each exposure was evaluated in an ordinal fash ion (nothing unusual, a mild reaction,
14 become somewhat ill and become very i ll). These categories were rated in the analysis using absolute values from 1 to 4 and more reaction resulted in higher score. The statements about symptoms and quality of life were categorized according to the five-point likert scale a nd respondents specified their level of agreement to each statement (strongly disagree, disagree, neu tral, agree, and strongly agree). The level of agreement or disagreement was scored in absolute values from 1 to 5, and more agreement resulted in higher statement score. The symptoms reported due to exposures were grouped according to the body area or system affected, and new responses variables were created with the symptoms. The values of these variables were calculated with the mean of values of each symptom in the group. These quantitative variable s created with the symptoms were: Face and Upper airways symptoms (complaints related to the face, nose and throat), Lower Respiratory symptoms (complaints related to trachea and lungs like cough, difficult breathing, wheezing or chest discomfort), Gastrointestinal symptoms (nausea, indigestion, diarrhea or getting gas), Neuro-psychological symptoms (headache, anxiety, trouble concentrating and become emotional) and Non-specific symptoms (discomfort, becoming sick, aching joints, trouble sleeping, nu mbness or tingling in hands or feet, hot or cold body sensation, and relieve of symptoms when getting away). Quality of life was defined from the last four statements included in the sensitivity questionnaire (missing work, missing social or business appointments feeling stress at home or work, and difficulty to interacting with other people) The value of this variable was also calculated with the mean of values from the last statements.
15 Data collection The main investigator distributed the questionnaires in Miami and Tampa. The locations selected were: libr aries and food courts in Flor ida International University (FIU) in Miami and University of South Florid a (USF) in Tampa, Publix food stores (one in Miami located directly across from FIU and other located in Tampa Palms area), and College of Public Health at USF. The que stionnaires were comp leted by volunteers and returned to the investigator pers onally in these places the same day. Statistical Analysis We did a descriptive analysis of the st atements about sensitivity, symptoms and quality of life, reported due to exposures The prevalence was measured through the absolute frequency and percentage of indivi duals with symptoms and sensitivity reported from exposure to inhaled odors, chemicals and irritants. The responses were crosstabulated with health variables and demogr aphics including gender, age by groups and ethnicity. Comparisons between Americans and Hispanics about self reported sensitivity, symptoms and quality of life were examined in greater detail to evaluate possible differences between these ethnic groups. Statistical analyses were performed using the software SPSS version 17.0. The comparisons in the prevalence of symptoms due to exposure to inhaled odors, chemical and irritants, and quality of life, between Hispanics and Americans, were done through two tailed t-test. Analysis of vari ance (ANOVA) was performed when sociodemographic and health variables were added to analysis. For all tests, the level of significance was p < 0.05 and the p-values were two sided.
16 Chapter IV Results Socio-demographic characterist ics of the study population Two hundred and ninety questionnaires we re collected from volunteers and 205 were selected for the analysis based on excl usion criteria; 47 were answered in Spanish. One hundred individuals were Americans a nd one hundred and five were Hispanics. More women (64.9%) than men (35.1%) partic ipated in the study although not by choice. The distribution of the p opulation by gender was similar between Americans and Hispanics, 66% of participants were women among Americans and 63.8% among Hispanics. The mean of age in the sample was 33 years, ranging from 16 to 85 years. The 55% of participants were younger than 30 years old; this group of age constituted the 54% among Americans and 56% among Hispanic s. The other groups of age constituted less than 20% each category and their distri bution was different in both ethnic groups. The majority of the participants in th e study were students or graduated from College or University (88.3%) and th e 56.6 % reported work in office 6 hours or more a day. Figures 1, 2 and Table 1 show these results.
18 Table 1: Demographic characteri stics of the study population Variable Frequency Percent Ethnicity Americans 100 48.8 Hispanics 105 51.2 Gender Male 72 35.1 Female 133 64.9 Age by Group Younger than 30 113 55.1 30 to 39 31 15.1 40 to 49 30 14.6 50 to 59 15 7.3 60 and older 16 7.8 Educational Level High School 24 11.7 College or University 138 67.3 Graduate Level 43 21.0 Workplace Location Enclosed vehicle 1 0.5 Indoor office 116 56.6 Indoor plant or industry 3 1.5 Outdoor 7 3.4 Other 14 6.8 Unemployed 64 31.2 Medical history and smoking habi t of the study population Medical history and smoking habit of all study participants are shown in Table 2. Medical conditions more frequent reported among the individuals in this study were Allergy and Respiratory problems, 37.6% and 31.2% respectively. Only 6.8% of participants were current smoker, 22% repor ted smoking habit in the last 10 years and one woman was pregnant. The dist ribution of participants within each one of these health and socio-demographic variables was sim ilar between Americans and Hispanics.
19 Table 2: Medical history of the study population Variable Frequency Percent History of Allergy 77 37.6 History of Respiratory problems 64 31.2 History of Non-Respiratory problems 19 9.3 History of Neuro-Psychiatric disorder 14 6.8 Physician diagnosis of Fibromyalgia, Chronic Fatigue Syndrome and Multip le Chemical Sensitivity 5 2.4 Use of steroids or antibiotics within the past 4 weeks 23 11.2 Smoker 14 6.8 Smoking habit in the last 10 years 45 22.0 Sensitivity and reaction to specific irritants in the study population The perception of being more sensitive th an the average person and the reaction level experienced by individuals in the study when they are exposed to cigarette smoke, automobile exhaust, strong smells, cologne, perfumes, scented candles and fresh paint vapors or fumes, is represented in Ta ble 3. Almost 30% (29.8%) of study population reported being more sensitive than the average person and women reported more than men (75%); the mean value to this statem ent was 2.95 when the ordinal variable was transformed and discontinue values between 1 and 5 were assigned to the answers. This means that almost the majority of particip ants in the study are more impartial than disagree in confirm that they are mo re sensible than the average person.
20 The reaction more frequent reported was to cigarette smoke; more than a half of individuals (60%) experience any reaction wh en are exposed; and the mean for this exposure was almost 2 (1.80) that represen t a mild reaction, when the variable is transformed in the analysis and discontinue values between 1 and 4 are assigned to the answers. The second more common reaction was to automobile exhaust; 57. 1% of participants in the study reported any reacti on to this exposure and the mean was 1.74; followed by fresh paint vapors or fumes with 55.6% of responders having any reaction and mean of responses of 1.77. As it is notice d, more than a half of persons have any reaction to these two exposures. However, less than 50% of pa rticipants in the study refer any reaction to strong smells, cologne, perfum es or scented candles (46.3%), and the mean for this exposure was 1.66 (Table 3).
21 Table 3: Sensitivity when exposure to i nhaled chemicals, irritants, odors and strong fragrances and reaction to specific irritants Variable Frequency Percent More sensitive to chemicals, irritants, odors and strong fragrances than the average person (Mean 2.95, SD 15.66 ) Strongly Disagree 25 12.2 Disagree 38 18.5 Neutral 81 39.5 Agree 44 21.5 Strongly Agree 17 8.3 Reaction to cigarette smoke (Mean 1.80, SD 0.76 ) Nothing unusual 82 40.0 A mild reaction 84 41.0 Become somewhat ill 37 18.0 Become very ill 2 1.0 Reaction to automobile exhaust (Mean 1.74, SD 0.73 ) Nothing unusual 88 42.9 A mild reaction 83 40.5 Become somewhat ill 33 16.1 Become very ill 1 0.5 Reaction to strong smel ls, perfumes or candles (Mean 1.66, SD 0.84 ) Nothing unusual 110 53.7 A mild reaction 64 31.2 Become somewhat ill 22 10.7 Become very ill 9 4.4 Reaction to fresh paint vapors or fumes (Mean 1.66, SD 0.84 ) Nothing unusual 91 44.4 A mild reaction 77 37.6 Become somewhat ill 30 14.6 Become very ill 7 3.4
22 Symptoms and Quality of Life due to expos ure to irritants in the study population The symptoms due to exposure to cigare tte smoke, automobile exhaust, strong smells, perfumes or fresh paint vapors were classified by body area or system affected. Participants in the study reported their leve l of agreement or disagreement with the different complaints and aspects related to qu ality of life. The answers were rated and the mean of values within each group of symptoms and quality of lif e are shown in Table 4. The mean of scores ranged from 1.73 to 2.38, this indicate that the majority of people in the study had any le vel of disagreement with the different symptoms or statements related to quality of life. The hi ghest mean value detected (2.38) was with lower respiratory symptoms (cough, difficu lty of breathing, wheezing, and tightness or pressure in the chest) that represent disagreement. Most people reported strong disagreement with gastrointestinal symptoms and complaints that affect the quality of life, when they are e xposed to irritants.
23 Table 4: Symptoms and quality of life due to exposure to cigarette smoke, automobile exhaust, strong smells perfumes or fresh paint vapors Variable N MinimumMaximum Mean (SD) Face and Upper Respiratory symptoms 205 1.00 5.00 2.23 .983 Lower Respiratory symptoms 205 1.00 5.00 2.38 .913 Gastrointestinal symptoms 205 1.00 5.00 1.88 .732 Neuro-Psychological symptoms 205 1.00 5.00 2.22 .947 Non-Specific symptoms 205 1.00 5.00 2.25 .758 Quality of Life 205 1.00 5.00 1.73 .797 Sensitivity and reaction to sp ecific irritants by ethnicity The level of agreement to the statement if the individual is more sensitive to inhaled chemicals, irritant s, odors and strong fragrances than the average person, and level of reaction to each irr itant was compared between Americans and Hispanics, these results are shown in Table 5. There were not statistically significan t differences between the means in both ethnics groups for any variable analyzed, p va lues were more than 0.05 in all tests. Most answers to reaction caused by different irri tants were nothing unusual (mean less than 2 in each group). In both ethnic groups, the mean of the responses about the question if the individual is more sensitive than the aver age person was close to 3 (2.97 in Americans and 2.93 in Hispanics), which correspond to almost impartiality with the answer.
24 Table 5: Sensitivity with exposure to inhale d chemicals, irritants, odors and strong fragrances and reaction to specific irritants by ethnicity Variable Ethnicity N Mean (SD) t p-value More sensitive to chemicals, irritants, odors or strong fragrances than average person American Hispanic 100 105 2.97 2.93 1.096 1.120 .237 .813 Reaction to cigarette smoke American Hispanic 100 105 1.84 1.76 .762 .766 .732 .465 Reaction to automobile exhaust American Hispanic 100 105 1.79 1.70 .743 .735 .918 .360 Reaction to strong smells, perfumes or scented candles American Hispanic 100 105 1.68 1.64 .875 .810 .356 .722 Reaction to fresh paint vapors or fumes American Hispanic 100 105 1.72 1.82 .805 .841 .861 .390 Symptoms and Quality of Life due to exposure to irritants by ethnicity Symptoms reported and quality of life when the individuals are exposed to cigarette smoke, automobile exhaust, strong sme lls, fragrances or fresh paint vapors were also compared between Americans and Hispanic s; the results are shown in Table 6. There were not statistically significant differen ces between both groups in any variable analyzed (p > 0.05). In all va riables most responses had va lues around 2 which mean that the individuals are disagree with the question.
25 Table 6: Symptoms and quality of life with exposure to cigarette smoke, automobile exhaust, strong smells, fragrances or fresh paint vapors by ethnicity Variable Ethnicity N Mean (SD) t p-value Face/Upper Respiratory Symptoms American Hispanic 100 105 2.294 2.171 .981 .985 .894 .372 Lower Respiratory Symptoms American Hispanic 100 105 2.348 2.426 .943 .886 -.615 .539 Gastrointestinal Symptoms American Hispanic 100 105 1.887 1.885 .713 .753 .017 .986 Neuro-Psychological Symptoms American Hispanic 100 105 2.275 2.169 .933 .962 .799 .425 Non Specific Symptoms American Hispanic 100 105 2.242 2.270 .737 .781 -.263 .793 Quality of Life American Hispanic 100 105 1.742 1.723 .754 .839 .167 .867
26 Ethnical differences on self-reported symptoms and quality of life cont rolling health and socio-demographic variables When the sensitivity with exposure to i nhaled chemicals, irritants, odors and strong fragrances and reaction to specific i rritants was compared between Americans and Hispanics, but having in consideration th e history of health problems and sociodemographic characteristics, statistically significant differences between both ethnic groups were detected in several analyses. If history of Allergy was c onsidered together with ethni city (Table 7), differences between Americans and Hispanic s were statistically signif icant (p = 0.028) when the participants in the study were asked if they are more sensitive to chemicals, irritants, odors or strong fragrances than the average person. Americans with history of Allergy tended to be more agree with th e question about the sensitivity; the mean in this group of individuals was 3.47 (around ne utral category) versus 3.05 among Hispanics; however, when the history of Allergy is not present, the Hispanics tended to be more agree (mean 2.87) than the Americans (mean 2.60). Figure 3 show the results w ithout consider the history of Allergy, which differs from the an alysis shown in Figure 4 where the Allergy modified the answers and disclosed the differences based in ethnicity.
28 Similar findings were detected with the reaction to cigarette smoke (Table 7) where the differences between Americans and Hispanics were statistically significant (p=0.012) depending on history of Allergy. A mild reaction was the average of the answers (mean 2.14) among Americans versus nothing unusual (mean 1.74) among Hispanics with history of Allergy, however among individuals without Allergy, the mean was higher in Hispanics and not hing unusual was the average of the answers in this group (mean 1.77 versus 1.62 in Americans). Figure 5 show the results w ithout consider the history of Allergy and Figure 6 the analysis where the Allergy disclosed differences between Americans and Hispanics.
30 Ethnicity did not interact w ith allergy history in predicting participants reaction to automobile exhaust, strong smells, perfum es, scented candles, and fresh pain vapor or fumes. These results from ANOVA analysis are summarized in Table 7.
31 Table 7: Sensitivity with exposure to inhale d chemicals, irritants, odors and strong fragrances and reaction to specific irritant s by ethnicity and history of Allergy Variable Ethnicity Allergy History Mean F p Value More Sensitive to chemicals irritants, odors or strong fragrances than the average person American No 58 2.603 Yes 42 3.476 4.914 .028 Hispanic No 70 2.871 Yes 35 3.057 Reaction to cigarette smoke American No 58 1.621 Yes 42 2.143 6.497 .012 Hispanic No 70 1.771 Yes 35 1.743 Reaction to automobile exhaust American No 58 1.586 Yes 42 2.071 3.145 .078 Hispanic No 70 1.657 Yes 35 1.771 Reaction to strong smells, colognes, perfumes or scented candles American No 58 1.431 Yes 42 2.024 3.371 .068 Hispanic No 70 1.586 Yes 35 1.743 Reaction to fresh paint vapors or fumes American No 58 1.534 Yes 42 1.976 .298 .586 Hispanic No 70 1.714 Yes 35 2.029
32 When analyses were done with the symp toms classified by body area or system affected and quality of life but consideri ng health and socio-demographic variables, notable differences were detected between Am ericans and Hispanics in several analyses. History of Allergy, smoking habit, used st eroids or antibiotic s within the last 4 weeks, and age interacted with ethnicity in predicting non-speci fic symptoms reported and quality of life. History of Allergy interact ed with ethnicity in pred icting non-specific symptoms (p = 0.046). Americans had higher values than Hispanics when they reported these symptoms due to exposure to irritants a nd the mean of the responses was 2.59 when reported history of Allergy versus 2.39 in Hispanics. However, among individuals without history of Allergy, the Hispanics tended to repor t more agreement with nonspecific symptoms when are exposed, the mean was 2.21 versus 1.98 in Americans. These findings are shown in Table 8; Fi gure 7 represents the comparison without consider history of Allergy and Figur e 8 with the Allergy considered.
34 No significant differences we re detected with the other types of symptoms (Table 8). The analysis about quality of life revele d statistically signi ficant interaction between ethnicity and history of Allergy (p = 0.32). The mean among Americans was 2.09; most of them were disagree with the stat ements related to quality of life; however in Hispanics, the tendency was to strongly disagreement (mean 1.80) Among individuals without history of Allergy, in contrast with those who ha d history, the Hispanics tended to less disagreement when they were asked a bout the interference with aspects related to quality of life. These results are presented in Table 8; Figure 9 shows the comparison
35 between Americans and Hispanic s in quality of life without consider the history of Allergy and Figure 10 cons idering the Allergy.
37 Table 8: Symptoms and quality of life with exposure to cigarette smoke, automobile exhaust, strong smells, fragrances or fres h pain vapors by ethnicity and history of Allergy Variable Ethnicity Allergy History Mean F p Value Face and Upper Respiratory Symptoms American No 58 1.980 Yes 42 2.727 2.444 .120 Hispanic No 70 2.065 Yes 35 2.383 Lower Respiratory Symptoms American No 58 2.079 Yes 42 2.719 1.638 .202 Hispanic No 70 2.323 Yes 35 2.634 Gastrointestinal Symptoms American No 58 1.703 Yes 42 2.143 3.056 .082 Hispanic No 70 1.861 Yes 35 1.936 Neuro-Psychological Symptoms American No 58 1.961 Yes 42 2.708 3.533 .062 Hispanic No 70 2.086 Yes 35 2.336 Non-Specific Symptoms American No 58 1.988 Yes 42 2.595 4.039 .046 Hispanic No 70 2.210 Yes 35 2.392 Quality of Life American No 58 1.487 Yes 42 2.095 4.649 .032 Hispanic No 70 1.682 Yes 35 1.807
38 When current smoking habit was analyzed, statistically significant interaction effect (p=0.021) between et hnicity and smoking habit was found for lower respiratory symptoms (cough, difficult of breathing, wheezing and chest tightness or pressure). This analysis disclosed that Hispanic smokers te nd to report these symptoms more than the Americans; the mean was 3.23 (impartiality w ith the answers was the average). However, among non-smokers, the answers were almost the same between Americans and Hispanics, the mean values in this cate gory of individuals were 2.37 (corresponds to disagreement with the response). Table 9 shows these results; Figure 11 shows lower respiratory symptoms reported without c onsider smoking habit and Figure 12 with smoking in the analysis. Table 9: Lower Respiratory symptoms by ethnicity and current smoker status Lower Respiratory symptoms (F= 5.421 p = 0.021) Ethnicity Smoker N Mean SD American No 92 2.374 .965 Yes 8 2.050 .611 Hispanic No 99 2.378 .882 Yes 6 3.233 .496
40 The report of neuro-psychological symp toms by participants in the study disclosed statistically sign ificant interaction between ethnicity and age (p = 0.012). Among Americans the means of the answers ranged around 2 or disagree with the complaints. The groups of 30 to 39 years old and 60 and older had the highest mean (2.67 and 2.60 respectively); however among Hispanic s, the group with the highest mean value was 50 to 59 years old, with a mean 3.56 that correspond to impartiality when complaining of this kind of symptoms. The values of the mean were more variable among the groups of age in Hispanics, from 1.78 (strongly disagree) to 3.56 (neutral). Table 10 summarizes these results.
41 Table 10: Neuro-psychological Sy mptoms by ethnicity and age Neuro-Psychological Symptoms (F= 3.311 p = 0.012) Ethnicity Age N Mean SD American Younger than 30 54 2.180 .866 30 to 39 17 2.676 1.120 40 to 49 13 1.961 .782 50 to 59 11 2.340 .903 60 and older 5 2.600 1.206 Hispanic Younger than 30 59 2.144 .865 30 to 39 14 1.785 .783 40 to 49 17 2.235 1.210 50 to 59 4 3.562 .426 60 and older 11 2.181 1.049 Other health variable that revealed differences among Hispanics and Americans regarding to quality of life when the individuals are exposed to irritants was recent use of steroids or antibiotics. When the use of thes e medications was considered together with ethnicity statistically signif icant interaction was found (p =0.037). The majority of the means values were close to disagreement with the answers. Americans who used antibiotics or steroids within the last 4 weeks had a mean value of 1.98; however among those who didnt use steroids or antibiotics, the Hispanics had the higher mean value, 1.76 versus 1.70 in Americans. In both groups, th e questions that define quality of life, although different, were answered in the range of disagreeme nt. The results are shown in Table 11; Figures 9 represent the comparis on without consider medications in the analysis and Figure 13 the use of ster oids or antibiotics are included.
42 Table 11: Quality of life by et hnicity and use of steroids or antibiotics within the past 4 weeks Quality of life (F= 4.389 p = 0.037) Ethnicity Use of steroids or antibiotics N Mean SD American No 87 1.706 .744 Yes 13 1.980 .806 Hispanic No 95 1.768 .851 Yes 10 1.300 .598
43 Results in Table 12 show no differences statistically significant between Americans and Hispanic in quality of life wh en gender was considered in the analysis. Table 12: Quality of life by ethnicity and gender Quality of life (F= 1.402 p = 0.238) Ethnicity Gender N Mean SD American Male 34 1.654 .648 Female 66 1.787 .804 Hispanic Male 38 1.815 .999 Female 67 1.671 .737
44 Chapter V Discussion Our results showed that there is not any statistically si gnificant differences between Americans and Hispanics when we compare both groups regarding to if the individual sensitivity to inhaled chemicals, irritants, odors or strong fragrances than the average person. Similar results were obtained when they were asked about reaction to specific irritants like cigare tte smoke, automobile exhaust, strong smells, colognes, perfumes, scented candles and fr esh paint vapors or fumes. Symptoms (by organ or sy stem involved) reported when the individuals are exposed to cigarette smoke, automobile exhaus t, strong smells, fragrances or fresh paint vapors were also evaluated a nd there was no statistically significant difference between Americans and Hispanics. Interaction between ethnicity and other socio-demographic and health variables were also tested. Results from these analyses showed statistically significant interaction between ethnicity and Allergy history. The effect of ethnicity on sensitivity to chemicals, irritants, odors or strong fr agrances changed depending on pa rticipants Allergy history. The same finding was detected when we analyzed the reaction of the individual to cigarette smoke, which was also statistically significant. In both situations, Americans with Allergy history reacted more strongly to mentioned exposures.
45 When we compared symptoms reported wh en the participants are exposed to cigarette smoke, automobile exhaust, strong smells, fragrances or fresh paint vapors, statistically significant intera ction effects were detected between ethnicity and Allergy history. This occurred with nonspecific symptoms. Once again, the effect of the ethnicity on non-specific symptoms changed dependi ng on participants Allergy history. Americans with Allergy history react ed more strongly to the exposures. Interaction between ethnicity and smok ing habit was found for predicting lower respiratory symptoms. In this case Hispanics who were current smoker reacted more strongly to irritants. However this finding should be interpreted with caution because there was low frequency of individuals w ho were smokers in the study population. In similar analysis, Age and ethnicity intera cted in predicting neuro-psychological symptoms. These results should also be interpreted with caution because the distribution of age in the study population was not homogene ous. There were few participants in the groups of 50 to 59 and 60 and more years old. When Quality of Life was analyzed, we found statistically signi ficant interactions between ethnicity and Allergy history or us e of steroids and antibiotics. Americans reported being more affected than Hispanics when reported history of Allergy and use of these medications. However with the use of the medications th e results should be interpreted with caution because few par ticipants reported the use of them. Sensitivity to common environmental irri tants is a frequent concern for the population. Several studies have been pub lished about self-reported symptoms or sensitivity to chemicals. Each study corrobor ates the influence of socio-demographic
46 variables, when individuals re port their symptoms and how it has affected their quality of life. Studies evaluating the prevalence rate of affected individuals when they are exposed to inhaled airborne chemicals, odors or irritants have reported estimates between 9% and 33%. Results of our study fell within this range, if we c onsider that 30% of individuals reported that they are more sensitive to inhaled chemicals, irritants, odors or strong fragrances than the average person. The increased prevalence of chemical se nsitivity among women is recognized in most studies (Bell, 1993; Berg, 2008; Joffr es, 2001; Johansson, 2005; Kreutzer, 1999; & Meggs, 1996). Our results concurred with the findings of the above mentioned reports, where the highest percentage of individuals reporting more sensitivity than the average person was women (75%). Socio-demographic and personal health ch aracteristics have been evaluated in most of the literature describing reports from sensitivity to chemicals and irritants, including ethnicity as a vari able within several in the analyses. However no one has selected specific ethnic groups to estab lishing comparisons, or confirm previously mentioned findings. Some investigations, like that one fr om the California population-based sample, indicated that multiple chemical sensitivity and self-assessed unusual sensitivity to chemicals are distributed homogeneously acr oss racial or ethnic groups. The authors justified that this homogeneous distribu tion might be explained by a physiological mechanism more than shared cultural or sociologic characteristics. Although the researchers suggested that cu ltural homogenizing effects of the media, the economy and
47 the educational system, which are the comm only shared psychosocial mechanisms could account for these findings. The aim of our study was to determine if there are differences between Americans and Hispanics in the prevalence of self-report ed sensitivity to common irritants found in the everyday environment, specific symptoms frequently reported and the interference with quality of life. The format of our questionnaire facil itated the comparison between Americans and Hispanics considering other socio-dem ographic and health variables that could influence in the report from participants. This allowed us to identify, differences between Americans and Hispanic that initially we re not detected in simpler analysis. The fact that the main investigator was present and witnessed the participation of volunteers, added credibility and formality to the completion and returning of the questionnaires. The questionnaire was eas y to complete, and no participant had complaints about its length or had any diffi culties with the completion the questions. The characteristics of study population we re fairly similar between Americans and Hispanics regarding the health variables. Although the distribution of some variables (history of non-respiratory problem, neuro-ps ychiatric disorder, physician diagnosis of Fibromyalgia, Chronic Fatigue Syndrome and Multiple Chemical and current smoking habit) was fairly uneven. There was a small number of participants in some categories could affect the results when we interpreting the interaction effects between the variables. Therefore the results would be treated with caution. One result that called our at tention was the reaction to the cigarette smoke and automobile exhaust, both common environmental contaminants. They were the most
48 frequent exposures that generated negative r eactions reported participants in this study. 60% of participants reported some kind of reaction to cigarette and 57.1% to automobile exhaust. These results were consistent with previous studies; tobacco smoke was the exposure scenario most likely to made res pondents very sick in the California study (Kreutzer et al., 1999), and automobile exhaus t was the second most prevalent exposure among all responders and the first among men in the study from Berg et al. in 2008. Reaction to strong smells, perfumes or candl es was the least reported reaction in this study, in contrast with the Bergs report wh ere it was the most prevalent exposure among all responders and women. When Americans were compared with Hispanics about their sensitivity to chemicals, irritants and fragrances and reac tion to specific irritants initially, these comparisons did not demonstrate any signi ficant difference between two ethnic groups. However, Americans reported being more sens itive than the average person. They were also more reactive to cigarette smoke, autom obile exhaust and strong smell, perfumes or candles than Hispanics. Hispanics react more to fresh paint vapors. Cigarette smoke, a common environmental contaminant, was the most reported exposure agent. On more in-depth analyses, when it was added the history of Allergy, significant differences were identified between American s and Hispanics regarding sensitivity. It happened when they reported being more se nsitive than the average person. A similar significant finding was detected when deali ng with reaction to cigarette smoke. As initially disclosed in bivariate analysis, Amer icans were more sensitive with exposure to recognized everyday irritants and react more to cigarette smoke than Hispanics. These results clearly demonstrated that Allergy hi story played an importa nt role in the way
49 people reported their sensitivity. The pivotal role of Allergy has such an impact that brings about ethnical differences otherwise obliterated. It is important indicate that we didnt included Asthma as part of Aller gy history. Asthma was classified within Respiratory problems. The symptoms categorized by organs or systems, due to exposure to common irritants were also evaluated initially without taking into c onsideration the influence of other variables. Important differences we re not detected between Americans and Hispanics in these first analyses. When Allergy history was added in subsequent analyses, statistically significant differen ces between Americans and Hispanics were detected. These important ethnic differences were noted when i ndividual reported Nonspecific symptoms. Americans with Allergy history reported more these unspecified complaints. A study in Germany about self-r eported chemical sensitivity, the most common complaints reported were headache, fatigue, sleep disturbances, joint pain, mood changes and nervousness (Hausteiner et al., 2005). Some of these symptoms were includes in our classification of non-specific symptoms. Both types of analyses disclosed that lo wer and upper respirat ory symptoms were the most frequent symptoms reported. These results confirms previous findings that airways symptoms are the most commonly reported when sensitivity to odors or irritants are evaluated (Johansson, 2005; Kreutzer, 1999; Meggs, 1996). Significant prevalence of lower lung complaints among individuals repo rting Asthma, hay fever and chemical odor intolerance were detected by Baldwin et al. in a community-based sample. Although there were identified important differences between Americans and Hispanics related to lower respiratory symp toms when Allergy hi story was considered,
50 significant differences were also found when smoking status was taki ng in consideration. In this particular scenario, it was demonstrated that smoki ng could really influence the way people reported symptoms related to trachea, bronchius and lung. Significant differences between both ethnic groups were found. In this situa tion, Hispanics with current smoking habit reported more these symptoms than Americans. Among nonsmoker the reports were fairly homogeneous. Age, also disclosed significant differences between Americans and Hispanics when individual reported neuro-psychologica l symptoms. Reports from these symptoms were not homogenously distributed be tween both groups. Among Americans, the individuals between 30 to 39 years old and th e oldest (60 and older) reported headache, anxiety, trouble with concen trating and becoming emotional more frequently. Among Hispanics, people between 40 and 59 more complaints were reported. Sensitivity and response to chemicals is known the being caused from multiple factors, which alter an indivi duals sensitivity, one of them is age. Because of this the influence of the age in the sensitivity has been evaluated in several studies. Most of them state that older individuals reported fewer sy mptoms caused by chemical inhaled and this finding account for the fact that it may be eas ier to control ones exposures to chemicals or irritants after retirement. Berg et al. found in their study that when the oldest group is excluded from the analysis, it is not detect ed any effect of age (Meggs, 1996; Berg, 2008). The age in our group was not distribut ed homogenously. The majority of our participants were younger than 30 years old, and the group more prevalent in reporting sensitivity to irritants or chem icals was not well represented.
51 Quality of life was analyzed in this study, through the interference of exposure to common irritants with social a nd occupational life. The major ity of respondents disagreed that such exposures interfere with their qua lity of life. An initial comparison between Americans and Hispanics was done where the results revealed that there were not significant differences between both groups. S ubsequent and more detailed analyses proved that important differences can distingu ish Americans from Hispanics. This fact was confirmed when Allergy history and prev ious use of steroids or antibiotics was considered in the analyses. Under these two conditions, Americans were the most affected in their social or occupational life when they state that they are exposed to common environmental contaminants. When gende r, age and other hea lth variables were controlled in our analyses, differences between Americans and Hispanics were not disclosed. It is known that quality of life is affect ed in any dimension when the individuals are exposed to everyday envi ronmental contaminants. Furt hermore the presence of odor can cause people to suspect exposures to be ha rmful to their health. Previous studies have recognized the association of exposure to airb orne chemicals with loss of occupation and adjustment in social life. Estimations of the frequency on specific activities affected have been identified (Berg, 2008; Caress, 2003; Johansson, 2005; Kreutzer, 1999). Multiple chemical sensitivity is an established diagnos is characterized by an increased sensitivity to chemicals. This diagnosis has achieved credibility in worker's compensation claims, tort liability, and regulatory actions for its repercussion in the wo rkplace (Gots, 1995). These studies have been exhaustive in their reports but have not evaluated if exposures that affect the quality of life, differ across ethnic groups. Their comparative analyses have
52 been concentrated more in uncovering age or gender differences in this matter. Our questionnaire allowed us to evaluate th e quality of life be tween Hispanics and Americans, as well as the influence of so cio-demographic and h ealth variables. When writing our works results, an interesting finding came to light, which was not different between Americans and Hispan ics. All mean values obtained with ANOVA analysis, compared with those in the initia l bivariate analysis, resulted higher when history of Allergy was considered in the analyses of sensitivity, reaction to specific exposures, symptoms and quality of life. This means a greater tendency to agree with the statements when the individual have a hist ory of Allergy. This confirm that if the individuals have a preexisting Allergy histor y, he or she can be more sensitive, reacts more, and reports more interfer ence with their social or work life when they are exposed to common irritants. Meggs et al. in his study about allergy and chemical sensitivity found that the prevalence of sensitivity to chem ical irritants is equivalent to that of allergy. Suffice it to say that this study is consistent with our results. Theoretical and rese arch implication Future investigation is required to exte nd our findings. Studies may focus on other ethnic groups that are also exposed to sp ecific chemicals or irritants in their environments, particularly under represented communities. Specific and detailed analyses about their sensitivity to their common irrita nts are needed. The results could explain the role of the tolerance in the way people report or react when are exposed. Also would help to explain more serious health problems th at starting with simple symptoms after dangerous exposures in the environment.
53 Workplaces could be a target for this ki nd of research. Exposure limits are based on objective measures of irrita tion onset as well as subjective complaints. The current instrument used as part of the process for determining exposure limits to chemicals or irritants in the workplace. Th e results from studies that evaluate population responses to environmental exposure could be solid basis for development policies and guidelines for occupational and residential environment. Limitations It was noted that during the data input, several participants responded all the questions about symptoms or sensitivity to sp ecific irritants with the same answers. It could reflect that they were not motivated. As a consequence, the absence of variability in some of the participants answ ers is one of the weaknesses of this study. This could have affected the results. Other limitation is the lack of variab ility in the study population regarding to some important socio-demographic variable s such as age, educational level and workplace location. This could have mask ed any significant difference between Americans and Hispanics. The majority of the participants were recruited from the Universities sites. There was not variability in the population studi ed regarding to workplace location and educational level. Most people reported wo rking in an office, being unemployed, and having college or university educational level. This could be a weak part of this study, because the prevalence or the differences det ected between these two ethnic groups could not be generalized to other sectors of th e population. People employe d in sectors like industrial, construction and agri culture, or with lower educa tion are exposed to different
54 environmental issues with other exposures. Th eir tolerance to irrita nts could be different, and therefore the probability of agreemen t or disagreement with the answers would change. Investigators have mentioned that Age and educational level are factors that alter an individual sensibility. Young age, for example, was associated with non-response, and individuals over 60 years ol d reported fewer symptoms and adjustment of behavior in the Danishs population study (B erg et al., 2007). Previous studies suggested that hypersensitivity is more common in individua ls of high level of education, because educated individuals are more probable to seek treatment and be diagnosed (Caress, & Steinemann, 2003)
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56 Doty, R.L., Deems, D.A., Frye, R.E., Pe lberg, R., & Shapiro, A. (1988). Olfactory sensitivity, nasal resistance, and autonomic function in patients with multiple chemical sensitivities. Arch Otolaryngol Head Neck Surg, 114(12), 1422-27. Fruin, S., Garcia, C., Hysong, T., & Mazzera, D. (2003). 2003 Progress Report and Research Plan on the Air Resources Boar ds Vulnerable Populations Research Program. Retrieved August, 2003, from http://www.arb.ca.gov/research/vprp/vprp.pdf Gebbers, J.O. (2001). The environment and auto immunity from external causes to inner conflicts. Praxis (Bern 1994), 90(44), 1913-22. Gots, R.E. (1995). Multiple chemi cal sensitivities--public policy. J Toxicol Clin Toxicol, 33(2), 111-3. Hausteiner, C., Bornschein, S., Hansen, J., Zilker, T., & Frst, H. (2005). Self-reported chemical sensitivity in Germany: a population-based survey. Int J Hyg Environ Health, 208(4), 271-8. Joffres, M.R., Williams, T., Sabo, B., & Fox, R.A. (2001). Environmental Sensitivities: Prevalence of Major Symptoms in a Referral Center: The Nova Scotia Environmental Sensitivitie s Research Center Study. Environ Health Perspect, 109(2), 161-5. Johansson, A., Brmerson, A., Millqvist, E., Nordin, S., & Bende, M. (2005). Prevalence and risk factors for self-reported odour intolerance: the Skvde population-based study. Int Arch Occup Environ Health, 78(7), 559-564.
57 Kreutzer, R., Neutra, R.R., & Lashuay, N. (1999). Prevalence of people reporting sensitivities to chemicals in a population-based survey. Am J Epidemiol 150(1), 1-12. Meggs, W.J., Dunn, K.A., Bloch, R.M., Goodman, P.E., & Davidoff, A.L. (1996). Prevalence and nature of a llergy and chemical sensitivity in a general population. Arch Environ Health 51(4), 275-82. Schiffman, S.S. (1998). Livestock Odors: Implications for Human Health and WellBeing. J Anim Sci, 76(5), 1343-55. Shusterman, D. (2001). Odor-associated he alth complaints: competing explanatory models. Chem Senses 26(3), 339-343. Williamson, S.E. (2007). A new questionnaire to determin e the frequency and severity of symptoms caused by inhaled odors, chem icals and irritants in normal subjects and their relation to health related quality of life. Unpublished master thesis, University of South Florida, Tampa.
59 Appendix A: Cover Letter To the volunteer: I am inviting you to participate in a research project to study symptoms that one develops after exposure to inhaled odors, chemicals and ai rborne irritants. Along with this letter, there is a questionnaire that as ks a variety of questions about this. It should take about 15 minutes to complete. I hope you will take the tim e to complete the survey and return it to me personally. Your participation is voluntar y, and there is not penalty if you do not participate. The development and results of this study will be used as the subject of my Thesis in the College of Public Health. It is not know of a ny risk to you if you decide to participate in this survey, and it is guaranteed that your responses will not be identified with you. I promise not to share any information that identifies you with anyone. You should not volunteer to put your name or any other inform ation on the questionnaire other than that which is requested. If you do not feel comf ortable completing the survey, discard it. Regardless of whether you choose to participat e, the results will be on file at the University of South Florida Shimberg H ealth Sciences Library after June 30, 2009. If you have any questions or concerns about completing the questionnaire or about being in this study, you may contact me at (305) 283-4579. If you have questions about your rights, general questions, complaints, or issu es as a person taking part in this study, you may also call the Division of Research Inte grity and Compliance of the University of South Florida at (813) 974-9343. Sincerely, and thank you, signature Carmen Perez, M.D. Chief Investigator
60 Appendix B: Additional Questionnaire Please, place an "X" in the appropriate box below 1 Ethnicity American Hispanic (Latino) Asian Other 2 Was your father born in the Unites States? YES NO 2a If not, where was he born? 3 Was your mother born in the United States? YES NO 3a If not, where was she born? 4 Were you born in the Unites States? YES NO 5 Educational level Primary or Elementary High School College or University Graduate level 6 Workplace Location (6 hours or more a day) Enclosed vehicle Indoor office Indoor plant/ industry Outdoor Other Unemployed If you are not American or Hispanic, pl ease disregard the remaining questions.
61 Appendix C: Demographic and Medical In formation Questionnaire 1 Gender Male Female 2 Age Please, place an "X" in the appropriate box below YES NO 3 Do you take antihistamines? 4 Do you get hay fever, seasonal a llergies, or alle rgic rhinitis? 5 Do you cough every day? 6 Do you suffer from respiratory problems? 7 Do you have asthma? 8 Do you have a normal sense of smell? 9 Are you a smoker? 10 Have you smoked in the last 10 years? 11 Have you received systemic steroi ds or antibiotics within the past 4 weeks? 12 Are you taking heart medication? 13 Do you have hepatitis or cirrhosis? 14 Do you suffer from renal failure? 15 Do you suffer from a ny neurologic disorder? 16 Do you suffer from any psychiatric disorder? 17 Do you take medication for depression? 18 Are you pregnant or think you might be? 19 Do you have eczema or hives? 20 Do you have arthritis? 21 Has a doctor ever told you that you have Fibromyalgia, Chronic Fatigue Syndrome, or Multiple Chemical Sensitivity?
62 Appendix D: Chemical, Odorant and Irritant Sensitivity Questionnaire This questionnaire asks about how you feel now and over the past year. Please, check the box that most closely describes how you feel. Strongly Disagree Disagree Neutral Agree Strongly Agree 22 I am more sensitive to inhaled chemicals, irritants, odors, or strong fragrances than the average person If I am around the following, I get this reaction: Nothing unusual A mild reaction Become somewhat ill Become very ill 23 Cigarette smoke 24 Automobile exhaust 25 Strong smells, cologne, perfumes or scented candles 26 Fresh paint vapors or fumes If I am exposed to cigarette smoke, automobile exhaust, strong smells, perfumes or colognes, or fresh paint vapors: Strongly Disagree Disagree Neutral Agree Strongly Agree 27 I suffer discomfort 28 I become sick 29 I develop burning in the skin of my face 30 I develop a funny sensation of the skin of my face 31 I develop eye irritation 32 I develop eye pain 33 I develop eye itching 34 I develop sore or burning in my nasal passages 35 I develop a sore throat 36 I feel nauseated 37 I develop indigestion 38 I develop diarrhea
63 If I am exposed to cigarette smoke, automobile exhaust, strong smells, perfumes or colognes, or fresh paint vapors: Strongly Disagree Disagree Neutral Agree Strongly Agree 39 I get gas 40 I may cough without phlegm 41 I may cough with phlegm up 42 I feel like I can't get my breath 43 I start wheezing 44 I feel tightness or pressure in my chest 45 I develop aching joints 46 I develop trouble sleeping 47 I develop numbness or tingling in my hands or feet 48 My body feels hot or cold 49 My symptoms ease if I can get away 50 I become emotional 51 I get a headache 52 I become anxious 53 I have trouble concentrating 54 I miss work 55 I miss social or business appointments 56 I feel stress at home or work 57 I find it hard to interact with other persons
64 Appendix E: Cover Letter and Questi onnaires translated to Spanish Carta de Presentacin Al voluntario: Yo lo estoy invitando a participar en un pr oyecto de investigacin para estudiar los sntomas que uno desarrolla despus de la exposicin a olores, qumicos e irritantes transportados por el aire. Junto con esta ca rta, hay un cuestionario con una variedad de preguntas acerca de esto. Debe tomar alrede dor de 15 minutos para completarlo. Yo espero que usted tomara el tiempo para co mpletar la encuesta y retornarla a m personalmente. Su participacin es voluntaria, y no hay penalidad si usted no participa. El desarrollo y resultados de este estudio sern usados como el tema de mi Tesis en el Colegio de Salud Pblica. No se conoce de algn riesgo para us ted si se decide a participar en esta encuesta y se le garanti za que sus respuestas no sern identificadas con usted. Se le promete no compartir alguna informacin que le identifique con alguien. Usted no debe voluntariamente poner su nombre o alguna otra informacin en el cuestionario que la requerida. Si usted no se siente c modo completando la encuesta, ignrela. Independientemente de si uste d seleccione o no participar, los resultados estarn en un archivo en la Biblioteca de Ciencias de Sal ud Shimberg de la Universidad del Sur de la Florida (USF) despus del 30 de Junio del 2009. Si usted tiene alguna pregunta o preocupacin acerca de completar el cuestionario o de estar en este estudio, usted puede contactar me al (305) 283-4579. Si usted tiene preguntas acerca de sus derechos, preguntas generales, quejas, o preocupacin como una persona tomando parte en este estudio, usted pue de tambin llamar a la Divisin de Cumplimiento e Integridad de Investigacione s de la Universidad de South Florida al (813) 974-9343. Sinceramente y muchas gracias, firma Carmen Perez, M.D. Investigador Principal
65 Appendix E (Continued) Cuestionario Adicional Por favor, coloque una "X" en la casilla apr opiada debajo 1 Etnicidad Americano Hispnico (Latino) Asitico Otra 2 Su padre naci en los Estados Unidos? SI NO 2a Si no, donde l naci? 3 Su madre naci en los Estados Unidos? SI NO 3a Si no, donde ella naci? 4 Usted naci en los Estados Unidos? SI NO 5 Nivel de escolaridad Primaria Secundaria Preuniversitario o Universitario Graduado de Universidad 6 Localizacin del rea de trabajo (6 horas o ms al da) Vehculo cerrado Oficina cerrada Planta interior/ industria Al aire libre Otro Desempleado Si usted no es Americano o Hispnico (L atino), por favor, no conteste las dems preguntas.
66 Appendix E (Continued) Informacin Mdica y Demogrfica 1 Sexo Masculino Femenino 2 Edad Por favor, coloque una "X" en la casilla apr opiada debajo SI NO 3 Usted toma antihistamnicos? 4 Usted sufre de fiebre del he no, alergias, o rinitis alrgica? 5 Usted tiene tos todos los das? 6 Usted sufre de problemas respiratorios? 7 Usted padece de Asma? 8 Usted tiene un sentido del olfato que es normal? 9 Usted es un fumador? 10 Usted ha fumado en los ltimos 10 anos? 11 Usted ha recibido esteroides o antibiticos dentro de las ltimas 4 semanas? 12 Usted est tomando medi cinas para el corazn? 13 Usted tiene hepatitis o cirrosis del hgado? 14 Usted sufre de fallo renal? 15 Usted sufre de algn problema neurolgico? 16 Usted sufre de algn problema psiquitrico? 17 Usted toma medicinas para la depresin? 18 Usted est embarazada o piensa que podra estarlo? 19 Usted sufre de eczema o urticaria? 20 Usted tiene artritis? 21 Algn doctor le ha dicho que us ted tiene Fibromialgia, Sndrome de Fatiga Crnica o Sensibilidad a Mltiple Qumicos?
67 Appendix E (Continued): Cuestionario sobre sens ibilidad a qumicos, olores e irritantes. Este cuestionario le pregunta como usted se siente ahora y como se sinti el ao pasado. Por favor, marque la casilla que mejo r describe como usted se siente. Totalmente desacuerdo Desacuerdo Neutral De acuerdo Totalmente de acuerdo 22 Yo soy ms sensible a inhalados qumicos, irritantes, olores, o fuertes fragancias que el promedio de las personas Si estoy alrededor de lo siguiente, me ocurre esta reaccin: Nada Inusual Una ligera reaccin Algo enfermo Muy enfermo 23 Humo de cigarro 24 Gases de automvil 25 Olores fuertes, colonias, perfumes o esencia de velas 26 Vapores de pintura fresca o humo Si me expongo al humo del cigarro, gases de automvil, olores fuertes, perfumes, colonias o vapores de pintura fresca: Totalmente desacuerdo Desacuerdo Neutral De acuerdo Totalmente de acuerdo 27 Sufro de molestias 28 Llego a enfermarme 29 Desarrollo quemazn en la piel de la cara 30 Desarrollo una sensacin extraa en la piel de la cara 31 Desarrollo irritacin en los ojos 32 Desarrollo dolor en los ojos 33 Desarrollo picazn en los ojos
68 Si me expongo al humo del cigarro, gases de automvil, olores fuertes, perfumes, colonias o vapores de pintura fresca: Totalmente desacuerdo Desacuerdo Neutral De acuerdo Totalmente de acuerdo 34 Desarrollo dolor o quemazn en la nariz 35 Desarrollo dolor de garganta 36 Siento nauseas 37 Desarrollo indigestin 38 Desarrollo diarreas 39 Me dan gases 40 Podra toser sin flemas 41 Podra toser con flemas 42 Siento que no puedo respirar 43 Empiezo a estornudar 44 Siento opresin o apretazn en el pecho 45 Desarrollo dolor en las articulaciones 46 Desarrollo problemas para dormir 47 Desarrollo entumecimiento, cosquilleo en las manos o pies 48 Mi cuerpo lo siento caliente o frio 49 Mis sntomas mejoran si puedo salir del lugar 50 Me pongo emocional 51 Me da dolor de cabeza 52 Me pongo ansioso 53 Tengo problemas para concentrarme 54 Dejo de trabajar 55 Pierdo citas sociales o de negocio 56 Siento nerviosismo en la casa o el trabajo 57 Encuentro difcil interactuar con otras personas
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Prevalence and influence on quality of life of symptoms caused by inhaled odors, chemicals and irritants :
b a comparison between Hispanics and Americans
h [electronic resource] /
by Carmen Perez.
[Tampa, Fla] :
University of South Florida,
Title from PDF of title page.
Document formatted into pages; contains 68 pages.
Thesis (M.S.P.H.)--University of South Florida, 2009.
Includes bibliographical references.
Text (Electronic thesis) in PDF format.
ABSTRACT: Efforts to estimate the population prevalence of chemical sensitivities have been limited and have yielded different estimates of the prevalence of affected individuals. Researchers recognize that people differ in their biological susceptibility to environmental contaminants as well as the amount of contaminant to which they are potentially exposed. Lack of information on the population prevalence of people, who report sensitivity to a chemical or many chemicals, as well as variables associated, has been recognized in previous studies (Kreutzer et al., 1999). In a more recent report, Berg et al., in 2007 reported the prevalence and consequences related to inhalation of chemicals in a Danish population. They concluded that the symptoms related to inhalation of airborne chemicals were common, especially among women. A small part of hat population reported that these symptoms affected social life or occupational conditions.Details in prevalence on severity of symptoms caused by inhaled odors, chemicals and irritants have not been investigated comparing populations based on ethnical differences. These differences could influence how individuals report their symptoms. This study evaluated the differences between Americans and Hispanics in sensitivity and symptoms related to inhalation of strong odors, chemical and irritants. We also evaluated the differences between both ethnic groups on quality of life due to these symptoms. A cross-sectional descriptive study was conducted between December 2008 and March 2009. A self-administered questionnaire was distributed to a total of 290 adults and 205 were selected for the analysis. American and Hispanic individuals of 16 years old or more were included. The responses were cross-tabulated and comparisons between means were performed using t-test and ANOVA.29.8% of study population reported being more sensitive than the average person and women reported more than men (75%). These findings were consistent with previous reported in the literature. The reaction more frequent reported was to cigarette smoke (60%). Statistically significant differences were identified between Americans and Hispanics regarding to sensitivity to chemicals, irritants, odors or strong fragrances and reaction to cigarette smoke when history of Allergy is present. Significant differences between both ethnic groups were detected with Lower Respiratory, Neuro-psychological and Non-specific symptoms; and Quality of life. These differences were disclosed when history of Allergy, smoking habit, used steroids or antibiotics within the last 4 weeks, and age were considered. Americans reported being more sensitive with exposure to recognized everyday irritants, react more to cigarette smoke and reported more Non-specific symptoms than Hispanics.Hispanic smokers tend to report Lower Respiratory symptoms more than the Americans. Hispanics between 50 to 59 years old reported more Neuro-psychological symptoms than Americans. Quality of life was more affected among Americans if they are exposed to common irritants, when Allergy history and use of steroids or antibiotics were considered.
Mode of access: World Wide Web.
System requirements: World Wide Web browser and PDF reader.
Advisor: Stuart Brooks, MD
x Environmental and Occupational Health
t USF Electronic Theses and Dissertations.