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Occupational and environmental exposures among Alaska Native and American Indian people living in Alaska and the Southwest United States.

Introduction

Most occupational and environmental health research has focused on associations between a particular hazard and health outcomes, such as asbestos exposure and lung cancer and respiratory diseases, radiation exposure among uranium miners, or insecticide application and risk of leukemia (Alevanja, Ward, & Reynolds, 2007; Archer, 1981; Frost, Harding, Darnton, McElvenny, & Morgan, 2008). Some hazard surveillance or monitoring data have been collected on potential chemical exposure in work settings (Boiano & Hull, 2001; Froines, Wegman, & Eisen, 1989). Research in the Arctic and subarctic regions has examined associations between environmental contaminants, wild food use, and health effects on indigenous people (Egeland, Feyk, & Middagh, 1998; Muckle, Ayotte, Dewailly, Jacobson, & Jacobson, 2001; Mulvad et al., 1996). No studies have looked at population-level exposures in the U.S. to a variety of hazards and very little hazard surveillance data have been collected on a national level (Froines et al., 1989).

For many occupational and environmental hazards, the effects from long-term exposure are not clearly understood. The actual health effects on an individual posed by any particular occupational or nonoccupational hazard depend on the toxicity of the substance, the dose and duration of exposure, an individual's genetic susceptibility to the effects of the hazard, and other behavioral and environmental influences such as use of tobacco. These hazards can cause a variety of health effects such as mutagenic, carcinogenic, neurologic, and endocrine impairment (Rom & Markowitz, 2006).

Many hazards have multiplicative effects. For example, a study of malignant mesothelioma found that Native American silversmiths routinely used asbestos mats to insulate worktables while making silver jewelry (Driscoll, Mulligan, Schultz, & Candelaria, 1988), which exposed them to a hazard (asbestos) that was seemingly unrelated to the occupational activity (silversmithing). Other studies among American Indian, Alaska Native, and First Nations peoples in Canada have explored the effects of heavy metals, mining dust, and lead on the health of native people (Denham et al., 2005; Patel et al., 2008; Wheatley & Paradis, 1995). Surveying a variety of potential hazards provides baseline data for future examination of multiple simultaneous exposure pathways.

No studies to date have surveyed the variety of occupational and environmental hazards to which American Indian and Alaska Native (AI/AN) people might be exposed. AI/AN people work in many occupations with the potential for exposure to health hazards, from uranium and coal mining and processing and agricultural work among Navajo people (Brugge & Goble, 2002; Dawson & Madsen, 1995; Roscoe, Deddens, Salvan, & Schnorr, 1995) to Alaska Native people who work in the Alaska petroleum or mining industry, but the prevalence of exposure has not previously been quantified. Additionally, AI/AN people are overrepresented among U.S. military veterans ages 18-64 in comparison to the general U.S. population so special relevance exists for exposure to military chemicals for those who are active duty or had prior service in the military (U.S. Census Bureau, 2003).

The Education and Research Towards Health (EARTH) Study is a multicenter study of AI/AN people designed to examine risk and protective factors for chronic diseases. We report here on the prevalence of self-reported exposure to occupational and environmental hazards in a large cohort of AI/AN people living in Alaska and the Southwest U.S. and compare the sociodemographic characteristics of persons who reported hazard exposure to those reporting no exposure. These data can be used to provide a baseline for further focused research on the associations between health and occupational and environmental hazards among AI/AN people.

Methods

Study Population

A detailed description of the study design, survey methods, and measurement

instruments for the EARTH Study is given elsewhere (Slattery et al., 2007). Participants from Alaska (95% Alaska Native and 5% American Indian) were recruited from one urban center and 26 small villages in southwest (Yukon-Kuskokwim Delta, primarily Yupik Eskimo), southeast (Panhandle, primarily Haida, Tlingit, and Tsimshian), and south central (Anchorage area, combination of Alaska Native ethnicities) Alaska. Most participating communities were located off the road system and were accessible only by airplane or seasonal access by snowmobile or boat. Navajo participants from the Southwest U.S. were recruited from 48 communities in northern New Mexico and Arizona.

Methods of recruitment included presentations to tribal groups and health care providers, informational tables with brochures and posters staffed by study personnel at community events or high-traffic locations, house-to-house recruiting, referrals, brochures and flyers in public locations, and public service announcements on local radio and in newspapers. In each community, attempts were made to enroll all eligible residents of the community who met the following criteria: self-identified Alaska Native or American Indian eligible for health care through the Indian Health Service, age >18 years of age, and able to give informed consent. Those who were pregnant or receiving chemotherapy were asked to participate at a later date due to health changes caused by those conditions. Our report considers data collected from 11,326 participants enrolled in the study from March 2004 through October 2007. Enrollment ranged from 2% to 49% (median = 29%) of those eligible for participation in each community. A greater proportion of persons in smaller communities participated in the study. Of the total study participants, only 0.2% (n = 19) did not do the occupational and environmental health questionnaire at all, and 0.5% (n = 55) were missing answers for at least one of the occupational and environmental hazard questions.

Data Collection

EARTH participants completed self- and interviewer-administered questionnaires on demographics, diet, physical activity, lifestyle and cultural practices, environmental exposures, cancer screening practices, medical and reproductive history, and family history of chronic diseases. In addition, height, weight, waist and hip circumference, blood pressure, fasting glucose, and a lipid panel were measured. Participants completed the occupational and environmental hazards questionnaire by using computer-assisted self-interview on touch-screen panels while listening to an audio version of the questionnaire by headphone in English, Dine' (Navajo), or Yup'ik (Eskimo) (Edwards et al., 2007).

The study protocol was approved by the Alaska Area Institutional Review Board (IRB), the Navajo Nation Human Research Review Board, the Indian Health Services IRB, the University of Utah IRB, the research and ethics committees and governing boards of each of the participating regional health corporations, and the tribal councils of the participating communities. All participants gave written informed consent before participating in the study.

Measurement of Occupational and Environmental Exposures

Tribal leaders and the study advisory board in the study areas determined local environmental hazards of concern. The final aggregated questionnaire included the major occupational and environmental hazards among the AI/AN populations surveyed. Participants were asked about possible exposures to nine hazards of interest. Participants were to answer yes if they had ever worked with or around specific materials at least once a month for six months or more and to include materials they may have been exposed to in and around their house or yard, at work, or during their spare time. Participants were also asked to include any self-employment or work done for family members or in a family business. Exposures queried included mineral or mining dust; pesticides including crop or livestock insecticides, weed killers, or fungicides; heavy metals such as cadmium or mercury; lead; radioactive materials including X-ray radiation; welding or silversmithing; asbestos; and gasoline or petroleum products (not including pumping gas for home use). Participants were also asked if they had ever served in the U.S. military and if yes, whether they had been exposed to biological or other chemical agents either in training or combat used in the military including Agent Orange or depleted uranium.

Statistical Analysis

Summary statistics provide an overview of the demographic characteristics of EARTH Study participants. Responses to exposure questions were analyzed by gender, age, education, language spoken at home, and EARTH Study center. Age group, sex, and study center differences were evaluated using the Chi-square test. All analyses were two-tailed and p < .05 was considered statistically significant. Multivariate logistic regression analysis was used to model prevalence of self-reported exposure to occupational and environmental hazards. Data from participants who answered "don't know" or who did not answer the question were excluded from the analysis. Prevalence odds ratios (OR) and corresponding 95% confidence intervals (CI) were calculated for the following variables of interest: age (continuous), gender, level of formal education, language spoken at home, and EARTH Study center. The models included all variables of interest. All analyses were conducted with the Statistical Packages for the Social Sciences version 15.0.

Results

Demographic descriptions of the Alaska (n = 3,821) and Southwest U.S. (n = 7,505) study populations are shown in Table 1. Participants in the EARTH Study ranged from age 18 to 94 (median 40.0) at the time of recruitment. More women than men enrolled in the study (61% vs. 39%). Over one-quarter of participants (26%) had not completed high school, with slightly more men than women not completing high school. Distributions of participants in both Alaska and the Southwest U.S. were similar in age and marital status. Compared to the Southwest U.S. study center, the Alaska study center had a slightly higher proportion of men than women enrolled (39% vs. 37%); a smaller proportion of low income participants (annual household income [less than or equal to] $15,000) (41% vs. 54%); fewer participants who spoke a language other than English at home (33% vs. 71%); and slightly more participants who reported their health status as excellent/very good/good (75% vs. 72%).

Only 19 (0.2%) participants did not answer the exposure questions at all. Some participants were not sure, however, if they had been exposed to specific occupational or environmental hazards queried. The percentage of participants who did not know whether they had been exposed varied by hazard type: asbestos (17%), lead (11%), heavy metals (10%), pesticides (7%), mining dust (6%), petroleum (4%), radioactive material (3%), welding/ silversmithing (1%), and military chemicals (0.2%). Almost 64% of participants reported no hazard exposure at all, 28% reported exposure to one to two hazards, and 8% reported three or more hazards (data not shown).

Table 2 shows the number and percentage of those who answered "yes" or "no" to the hazard questions. The top three most commonly reported hazards were petroleum products (15%), pesticides (11%), and welding/silversmithing (9%). These were followed by asbestos (9%), military chemicals (8%), and mining dust (7%). The least commonly reported hazards were heavy metals, lead, and radioactive material, each reported by about 5% of study participants. The prevalence of reported hazard exposure varied by sex, age, and study center: reported hazard exposure was higher among men than women, higher among participants in the middle age bracket (40-59), and higher among those living in the Southwest U.S. compared to Alaska.

These associations were explored further in multivariate logistic regression models of occupational and environmental hazards as shown in Table 3. Younger participants were more likely to report exposure to most of the occupational and nonoccupational hazards that were queried, with the exception of heavy metals and petroleum. The odds of exposure to the various hazards among men were two to eight times the odds among women. Non-high school graduates reported more exposure to mining dust, radioactive material, welding/silversmithing, and petroleum (adjusted OR = 0.80, 0.65, 0.82, and 0.80, respectively). The odds of reported exposure for those who spoke an Alaska Native or American Indian language at home were 1.21 to 1.59 times higher than the odds among those who spoke only English in the home. By study center, ORs were significantly higher for the Southwest U.S. study center than Alaska (range: adjusted OR = 1.61 for lead to OR = 5.12 for pesticides) except for exposure to petroleum, where the odds were lower among Southwest U.S. participants (adjusted OR = 0.72). A significant difference did not exist in the odds of radioactive material exposure between the two study centers.

Discussion

These data summarize self-reported occupational and environmental hazards and associated sociodemographic factors for American Indian and Alaska Native study participants. To our knowledge, no data were available on population-level prevalence exposures for a large number of American Indian and Alaska Native people prior to our study. Exposure to various occupational and environmental hazards was reported by 5% to 15% of study participants. The actual exposure prevalence could be higher, since some participants did not know if they had been exposed to certain hazards, in particular asbestos, lead, and heavy metals. The types of hazards reported represent a range of industries and industrial by-products and are associated with diverse health effects. The highest reported hazard among the Alaska participants was petroleum products (18%), while the highest reported type of hazard in the Southwest U.S. was pesticides (15%), both of which can have mutagenic and carcinogenic effects on human health (Bhalli et al., 2008; Lohi, Kyyronen, Kauppinen, Kujala, & Pukkala, 2008; Orsi et al., 2009; Paz-y-Mino, Lopez-Cortes, Arevalo, & Sanchez, 2008; Perrotta, Staines, & Cocco, 2008). Our study found that male sex, lower educational attainment, and speaking an Alaska Native or American Indian language in the home were associated with higher likelihood of hazard exposure. Compared to Alaska participants, those living in the Southwest U.S. were more likely to report exposure to all but one of the occupational and environmental hazards studied.

Unfortunately, no other national-level surveys exist to compare with these data. In 1981-1983 the Centers for Disease Control and Prevention/National Institute for Occupational Safety and Health (CDC/NIOSH) completed a National Occupational Exposure Survey (NOES). NOES resulted in a list of substances and an estimated number of workers exposed but did not examine the percentage of the population exposed or potential simultaneous exposures, nor did it estimate potential differential exposure by race/ethnicity. The National Health Interview Survey (NHIS) in 1988 included an occupational health supplement that included exposure to pesticides (6.1% of those surveyed, compared with 10.8% among EARTH Study participants) but did not query other exposures included in the EARTH Study. No occupational health supplement has been conducted as part of the NHIS since 1988 (U.S. Department of Health and Human Services & National Center for Health Statistics, 1988). The NIOSH Surveillance Strategic Plan includes a proposal for a new nationally representative hazard survey that might provide more of this type of data in the future, and CDC's National Center for Environmental Health has called for increased surveillance and tracking systems in order to track exposures and health effects potentially related to environmental hazards (National Institute for Occupational Safety and Health, 2001; U.S. Department of Health and Human Services, 2006).

Although ours is the largest study of its kind to date, it has limitations. The EARTH Study queried participants about hazards experienced at work or around the house or yard and during military service. No data were collected on dose, duration, or when in the lifespan exposure occurred. No data were gathered on environmental hazards that occur in residential or community settings, such as persistent organic pollutants (POPs). POPs are of concern to indigenous peoples of Alaska and across the Arctic due to their historic use in military facilities and long distance transport via ocean and air currents that deposit contaminants in the Arctic from distant industrial and agricultural sources. In addition to contaminating the air, land, and water, these chemicals bioaccumulate in the tissues of wild animals and plants that are then used for food by northern indigenous peoples (Arctic Monitoring and Assessment Program, 1997; Chan, Kim, Khoday, Receveur, & Kuhnlein, 1995; Rubin et al., 2001; Wheatley & Paradis, 1995).

No occupational or environmental monitoring was done to validate self-reported hazard exposure. Other studies, however, have found good reliability and validity between self-administered occupational health history questionnaires and other assessments of exposure (Eskenazi & Pearson, 1988; Lewis et al., 2002; Rosenstock, Logerfo, Heyer, & Carter, 1984). It is possible that prevalence of hazard exposure may actually be higher than reported as many participants in our study were unsure of past exposures.

Conclusion

Future research into the association of health and occupational and environmental hazards among American Indian and Alaska Native people is necessary to understand the types of hazards and their associated health risks. The results of our study provide a better understanding of the epidemiology of occupational and environmental exposures experienced by American Indian and Alaska Native people. It also provides baseline surveillance data to facilitate future exposure-response analyses. Further studies should include data on dose and duration as well as expand analyses to include study of environmental contaminants in wild foods consumed by AI/AN populations.

Acknowledgements: This study was funded by grants CA88958 and CA96095 from the National Cancer Institute. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official view of the National Cancer Institute or the Indian Health Service. We would like to acknowledge the contributions and support of the Indian Health Service, the Alaska Native Tribal Health Consortium Board of Directors, Southcentral Foundation, Southeast Alaska Regional Health Consortium, and the Yukon-Kuskokwim Health Corporation.

Corresponding Author: Diana Redwood, Senior Program Manager, Alaska Native Tribal Health Consortium, 4000 Ambassador Dr., Anchorage, AK 99508. E-mail: dredwood@anthc.org.

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Diana Redwood, MPH, MS, Alaska Native Tribal Health Consortium

Anne P. Lanier, MPH, Md, Alaska Native Tribal Health Consortium

Michael Brubaker, MS, Alaska Native Tribal Health Consortium

Laurie Orell, MPH, Alaska Native Tribal Health Consortium

Lillian Tom-Orme, PhD, University of Utah

Carmen George, MS, university of Colorado Denver

Sandra Edwards, PhD, University of Utah

Martha Slattery, PhD, University OF Utah
TABLE 1

Demographic Characteristics of Alaska Native and Southwest U.S.
American Indian People Participating in the Education and
Research Toward Health (Earth) Study

Demographic                              Alaska      Southwest U.S.
                                          n (%)          n (%)

Total                                  3821 (33.7)    7505 (66.3)
Age group
  18-39                                1873 (49.0)    3760 (50.1)
  40-59                                1517 (39.7)    3006 (40.1)
  60+                                  431 (11.3)      739 (9.8)
Sex
  Male                                 1501 (39.3)    2765 (36.8)
  Female                               2320 (60.7)    4740 (63.2)
Education
  Less than high school                851 (22.5)     2022 (27.0)
  High school or higher                2932 (77.5)    5455 (73.0)
Employment status
  Employed or self-employed            1595 (41.7)    3228 (43.0)
  Not currently employed               2226 (58.3)    4277 (57.0)
Marital status
  Married/living as married            1630 (42.8)    3272 (43.6)
  Separated/divorced/never married
                                       2176 (57.2)    4225 (56.4)
Annual household income
  [less than or equal to] $15,000      1342 (41.1)    3428 (53.7)
  $15,001-$25,000                      526 (16.1)     1058 (16.6)
  $25,001-$35,000                      446 (13.7)      771 (12.1)
  $35,001-$50,000                      444 (13.6)      624 (9.8)
  [greater than or equal to] $50,001   504 (15.5)      504 (7.9)
Language spoken at home
  Native only                           302 (7.9)      896 (12.0)
  English only                         2541 (66.8)    2176 (29.2)
  Both native and English              960 (25.2)     4375 (58.7)
Self-reported health status
  Excellent/very good/good             2863 (75.0)    5337 (72.1)
  Fair/poor                            954 (25.0)     2061 (27.9)

Demographic                               Total
                                          n (%)

Total                                  11,326 (100)
Age group
  18-39                                5633 (49.7)
  40-59                                4523 (39.9)
  60+                                  1170 (10.3)
Sex
  Male                                 4266 (37.7)
  Female                               7060 (62.3)
Education
  Less than high school                2873 (25.5)
  High school or higher                8387 (74.5)
Employment status
  Employed or self-employed            4823 (42.6)
  Not currently employed               6503 (57.4)
Marital status
  Married/living as married            4902 (43.4)
  Separated/divorced/never married
                                       6401 (56.6)
Annual household income
  [less than or equal to] $15,000      4770 (49.4)
  $15,001-$25,000                      1584 (16.4)
  $25,001-$35,000                      1217 (12.6)
  $35,001-$50,000                      1068 (11.1)
  [greater than or equal to] $50,001   1008 (10.5)
Language spoken at home
  Native only                          1198 (10.6)
  English only                         4717 (41.9)
  Both native and English              5335 (47.4)
Self-reported health status
  Excellent/very good/good             8200 (73.1)
  Fair/poor                            3015 (26.9)

TABLE 2

Number and Percentage of American Indian and Alaska Native
Participants Reporting Occupational and Environmental Exposures
by Sex, age, and Alaska and Southwest U.S. Study Center of the
Education and research Towards Health (Earth) Study *

Exposure                 Total n (%)             Sex

                                           Men         Women
                                          n (%)        n (%)

Petroleum                1673 (15.4)   1256 (31.0)   417 (6.1)
Pesticides               1131 (10.8)   599 (15.3)    532 (8.1)
Welding/                 1055 (9.4)    821 (19.7)    234 (3.3)
  silversmithing
Asbestos                  794 (8.5)    501 (14.4)    293 (5.0)
Military
  chemicals ([dagger])    881 (7.8)    754 (17.7)    127 (1.8)
Mining dust               686 (6.5)    457 (11.6)    229 (3.4)
Heavy metals              518 (5.1)    397 (10.7)    121 (1.9)
Lead                      500 (5.0)     363 (9.8)    137 (2.2)
Radioactive material      495 (4.5)     247 (6.1)    248 (3.6)

Exposure                                  Age

                            18-39        40-59         60+
                            n (%)        n (%)        n (%)

Petroleum                 857 (15.8)   717 (16.6)    99 (8.8)
Pesticides                510 (9.6)    507 (12.2)   114 (10.7)
Welding/                  529 (9.5)    427 (9.6)     99 (8.6)
  silversmithing
Asbestos                  305 (6.6)    408 (10.9)    81 (8.2)
Military
  chemicals ([dagger])    253 (4.5)    453 (10.0)   175 (15.0)
Mining dust               285 (5.4)    335 (8.0)     66 (6.1)
Heavy metals              280 (5.5)    203 (5.1)     35 (3.3)
Lead                      231 (4.6)    228 (5.8)     41 (4.0)
Radioactive material      221 (4.0)    222 (5.1)     52 (4.6)

Exposure                        Study Center

                            Alaska      Southwest U.S.
                            n (%)           n (%)

Petroleum                 658 (17.9)     1015 (14.1)
Pesticides                116 (3.2)      1015 (14.7)
Welding/                  158 (4.2)       897 (12.1)
  silversmithing
Asbestos                  190 (6.0)       604 (9.7)
Military
  chemicals ([dagger])    447 (11.7)      434 (5.8)
Mining dust                91 (2.5)       595 (8.5)
Heavy metals              106 (3.1)       412 (6.1)
Lead                      123 (3.7)       377 (5.7)
Radioactive material      154 (4.2)       341 (4.7)

Note. p < .05 for all differences except welding by age, military
chemicals by sex and age, and radioactive material by study
center.

* Of participants who answered the question.

([dagger]) Of those participants who reported military service.

TABLE 3

Multivariate Associations With Occupational and Environmental
Exposures Among American Indian and Alaska Native (Ai/An) People
Participating in the Education and Research Toward Health (Earth)
Study *

Demographic                   Petroleum    Pesticides     Welding/
                             OR (a) (95%   OR (95% Cl)   Silversmith
                               Cl (a))                   OR (95% Cl)

Age, years                      1.01          0.99          1.00
                               (1.00-        (0.99-      (0.99-1.00)
                                1.01)         1.00)
                              ([double      ([double
                              dagger])      dagger])

Sex

Female ([paragraph])            1.00          1.00          1.00

Male                            6.87          2.20          7.54
                               (6.09-      (1.94-2.5)      (6.46-
                                7.74)      ([dagger])       8.80)
                             ([dagger])                  ([dagger])

Education

Less than high                  1.00          1.00          1.00
school ([paragraph])

High school                     0.80          0.91          0.82
or higher                      (0.70-      (0.79-1.06)     (0.70-
                                0.92)                       0.96)
                              ([double                    ([double
                              dagger])                    dagger])

Language spoken at home

English only ([paragraph])      1.00          1.00          1.00

AI/AN language                  1.21           1.2          1.59
                               (1.07-        (1.04-        (1.35-
                                1.37)         1.40)         1.87)
                              ([double      ([double     ([dagger])
                              dagger])      dagger])

EARTH Study center

Alaska ([paragraph])            1.00          1.00          1.00

Southwest U.S.                  0.72          5.12          3.05
                               (0.63-        (4.16-        (2.53-
                                0.81)         6.29)         3.68)
                             ([dagger])    ([dagger])    ([dagger])

Demographic                   Asbestos      Military     Mining Dust
                             OR (95% Cl)    Chemicals    OR (95% Cl)
                                           ([section])
                                           OR (95% Cl)

Age, years                      0.98          1.00          0.99
                               (0.98-      (0.99-1.01)     (0.98-
                                0.99)                       0.99)
                             ([dagger])                  ([dagger])

Sex

Female ([paragraph])            1.00          1.00          1.00

Male                            3.34          1.62          3.93
                               (2.87-      (0.98-2.68)     (3.32-
                                3.89)                       4.64)
                             ([dagger])                  ([dagger])

Education

Less than high                  1.00          1.00          1.00
school ([paragraph])

High school                     0.89          0.60          0.80
or higher                    (0.75-1.05)   (0.35-1.03)     (0.67-
                                                            0.97)
                                                          ([double
                                                          dagger])

Language spoken at home

English only ([paragraph])      1.00          1.00          1.00

AI/AN language                  1.11          1.14          1.34
                             (0.93-1.32)   (0.80-1.63)     (1.11-
                                                            1.63)
                                                          ([double
                                                          dagger])

EARTH Study center

Alaska ([paragraph])            1.00          1.00          1.00

Southwest U.S.                  1.71          1.80          3.63
                               (1.42-        (1.28-        (2.85-
                                2.06)         2.54)         4.61)
                             ([dagger])    ([dagger])    ([dagger])

Demographic                  Heavy Metals      Lead       Radioactive
                             OR (95% Cl)    OR (95% Cl)    Material
                                                          OR (95% Cl)

Age, years                       1.01          0.99          0.99
                                (1.00-      (0.99-1.00)     (0.98-
                                1.02)                        1.00)
                               ([double                    ([double
                               dagger])                    dagger])

Sex

Female ([paragraph])             1.00          1.00          1.00

Male                             6.30          4.94          1.78
                                (5.11-        (4.04-        (1.48-
                                7.78)          6.05)         2.14)
                              ([dagger])    ([dagger])

Education

Less than high                   1.00          1.00          1.00
school ([paragraph])

High school                      1.08          0.90          0.65
or higher                    (0.88-1.33)    (0.73-1.11)     (0.51-
                                                             0.82)
                                                          ([dagger])

Language spoken at home

English only ([paragraph])       1.00          1.00          1.00

AI/AN language                   1.32          1.03          1.00
                                (1.07-      (0.83-1.27)   (0.81-1.23)
                                1.63)
                               ([double
                               dagger])

EARTH Study center

Alaska ([paragraph])             1.00          1.00          1.00

Southwest U.S.                   1.91          1.61          1.18
                                (1.51-        (1.29-      (0.95-1.46)
                                2.41)          2.02)
                              ([dagger])    ([dagger])

(a) OR = odds ratio; CI = confidence interval.

* ORs adjusted for all other variables in the model (i.e., all
listed characteristics).

([section]) Of those participants who reported military service.

([double dagger]) p < .05 (two-tailed).

([dagger]) p < .001 (two-tailed).

([paragraph]) Reference category.
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Article Details
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Title Annotation:ADVANCEMENT OF THE SCIENCE
Author:Redwood, Diana; Lanier, Anne P.; Brubaker, Michael; Orell, Laurie; Tom-orme, Lillian; George, Carmen
Publication:Journal of Environmental Health
Article Type:Report
Geographic Code:1USA
Date:May 1, 2012
Words:5280
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