Factors Related to the Use of Synthestic Pesticides among Agricultural Rural Communities in Colombia

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Factors Related to the Use of Synthestic Pesticides among Agricultural Rural Communities in Colombia Implications for Human Health, Rural Development and Conservation
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1 online resource (171 p.)
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english
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Polanco, Ysabel
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University of Florida
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Gainesville, Fla.
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Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Public Health (PhD), Behavioral Science and Community Health
Committee Chair:
Curbow, Barbara
Committee Members:
Burns, Alba
Rozensky, Ronald H
Young, Mary E
Guillette, Elizabeth A

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Subjects / Keywords:
agriculture -- health -- perceptions -- pesticides
Behavioral Science and Community Health -- Dissertations, Academic -- UF
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Public Health (PhD) thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

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Abstract:
Conventional agricultural practices are often contrary tohuman health and environmental conservation. Use of and exposure to pesticidesin agricultural communities in tropical countries is a pressing public healthproblem and an important facet of environmental degradation.  This research project was undertaken bydocumenting use and exposure behaviors among agricultural communities in SanCristobal, Antioquia (Colombia). The research questions were:  (1) What are the primary factors associatedwith the use of pesticides and do those factors differ between pesticide usersand agroecological adherents? (2) How do campesino pesticide users and agroecologicaladherents (non-pesticide users) differ in their attitudes and beliefs withregards to pesticide use and exposure? and (3) How do these factors influencecampesinos’ behaviors associated with pesticide use and exposure? I implementedqualitative and quantitative methods in this investigation. The qualitativeapproach was based on community participatory ethnographic research. The latterinvolved participant observation, interviews, and focus groups aimed atexisting pesticides users and agroecological adherents. The quantitative approachused questionnaires to derive demographic information, scale-based evaluationsof attitudes and beliefs, pesticides decision making, perceived confidence, andperceived control. Findings showed that the most relevant factors related topesticide use and their categories included: a) individual: beliefs, attitudesand knowledge; b) interpersonal: family support and cultural acceptance ofpesticide use; c) economic: fear of living within financially unviableconstraints, market conditions and lack of economic support from thegovernment; d) cultural: collective acceptance or tolerance of pesticide useand exposure and onset of negative reactions when stopping pesticide use; e)political: deficient regulations for controlling pesticide use control andadequate utilization of protective equipment. Pesticide usersexperienced the most apprehension regarding stopping pesticide use as theyoften believed pesticides allow them to obtain better crop yields and,therefore, higher monetary gains. Pesticide users lacked a positive attitudetoward personal protection equipment, regardless of the risks to which they maybe exposed. Pesticide training was deficient in this population showing a clearneed to improve safety conditions and training to reduce occupational hazards.Future studies should explore with greater detail these attitudes and beliefsso as to promote mid- to long-term public health interventions that directlyaddress the sense of food and income insecurity found among the population ofpesticides users, which blocks their transition into a non-pesticide scenariofor agricultural production. Over the short-term, public health programs shouldcontinue to educate the population of pesticide users on the immediate risks ofexposure.
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In the series University of Florida Digital Collections.
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Includes vita.
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This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Ysabel Polanco.
Thesis:
Thesis (Ph.D.)--University of Florida, 2012.
Local:
Adviser: Curbow, Barbara.
Electronic Access:
RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2014-08-31

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1 FACTORS RELATED TO THE USE OF SYNTHETIC PESTICIDES AMONG AGRICULTURAL RURAL COMMUNITIES IN, COLOMBIA: IMPLICATIONS FOR HUMAN HEALTH, RURAL DEVELOPMENT AND CONSERVATION B y Y SABEL POLANCO A DISSERTATION PRESENTED TO THE GRAD UATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2012

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2 2012 Y sabel Polanco

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3 To my family, my parents, h usband, Luna and Inti Miguel that gave me always an unconditional support and understanding

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4 ACKNOWLEDGMENTS I owe gratitude to my parents Beatriz Lopez de Mesa and Jorge Eduardo Polanco and family Luna, Inti Miguel and Sergio for all the support and love they provided for me during this proce ss. I thank Miguel Angel Restrepo, his life example, inspired me to build this project. I also thank Jos Sanchez the agronomy student who assisted me during data collection and analysis and who always exhibited great enthusiasm towards the project. I tha nk the agricultural community in San Cristbal that opened the doors for me and helped actively during the research process. This community also taught me many important things about life, health and agriculture. I thank the Asociacin de Campesinos Agric ultores de Boquern (Agricultural Campesino Association of Boqueron) (ACAB) for facilitating access to some of the members of the association who participated in the study in the non pesticide users group. I show my gratitude to Corporacin para la Investi gacion y el Ecodesarrollo Regional (Corporation for Investigation and regional Ecodevelopment ( CIER, NGO) for helping me establish preliminary contact with the community focus of this study. I deeply thank my advisor Dr Barbara Curbow. She oriented me aca demically throughout my doctoral studies and provided me also fundamental emotional support. I also want to express my gratitude to Dr Mary Ellen Young, who was my professor in the qualitative analysis part of this research and guided me step by step in my thinking process with the qualitative data; to Dr. Alba Amaya Burns for sharing with me her experience and knowledge on public health issues in Latin America and for promoting an in depth analysis of health disparities as a fundamental aspect of public he alth programs for our communities; to Dr. Elizabeth Gillette for opportunely and persistently pointing out the connection between health and the environment, an approach that

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5 helped me think about our responsibility in fostering human health in close rela tionship with the health of our now over contaminated planet. I also want to thank Dr Ronald Rozenski for his advice in the process of developing this dissertation, as well as Dr. Juan Carlos Salazar, statistics professor at the Universidad Nacional de Co lombia, who assisted me in accomplishing the statistical analysis for this project. I want to thank Evelyn King Marshall for her friendship, all the company and emotional support she gave me throughout my years in the PhD program. I thank my colleagues in the Department of Preventive Medicine and Public Health in the School of Medicine, University of Antioquia, Colombia for their academic advice in the project. Great appreciation goes also to all of the sources of financial support as this aspect of rese arch is always of was of paramount importance in undertaking a scientific project. I express my gratitude to the Compton Foundation and the diligent support provided by Susan Jacobson in awarding me the International Fellowship in Environment and Sustaina ble Development which was a fundamental source of financial support for this project.

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6 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ .......... 10 LIST OF FIGURES ................................ ................................ ................................ ........ 12 ABSTRACT ................................ ................................ ................................ ................... 13 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 16 Overview ................................ ................................ ................................ ................. 16 Specific Aims ................................ ................................ ................................ .......... 17 Broad Research Questions ................................ ................................ .............. 18 Research Purpose ................................ ................................ ............................ 19 Methods ................................ ................................ ................................ .................. 19 Discussion and Conceptualization of the Problem ................................ .................. 20 Overview of Chapters ................................ ................................ ............................. 21 Summary ................................ ................................ ................................ ................ 22 2 LITERATURE REVIEW ................................ ................................ .......................... 24 Introductory Remarks ................................ ................................ .............................. 24 Pesticide Use as an Important Public Health Issue in the World ............................ 25 Types of Synthetic Pesticides in the World ................................ ....................... 25 Pesticide Utilization and Effects ................................ ................................ ....... 27 Pesticide Use in Colombia ................................ ................................ ...................... 30 Types of Pesticides use in Colombia ................................ ................................ 30 Relevant Pesticide Regulations in Colombia ................................ .................... 31 Effects of Pesticide Use and Exposure on Human Health ................................ ...... 34 Recommendation for Future Research ................................ ................................ ... 38 Summary ................................ ................................ ................................ ................ 39 3 PESTICIDES: CONTEXTUAL, INTERPERSONAL AND INDIVIDUAL FACTORS ................................ ................................ ................................ ............... 45 Summary ................................ ................................ ................................ ................ 45 Introductory Remarks ................................ ................................ .............................. 45 Study Aims and Research Questions ................................ ............................... 47 Contextual Information of the Research Setting ................................ ............... 48 Methods ................................ ................................ ................................ .................. 49 Reflexivity Statement ................................ ................................ ........................ 50

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7 Participants ................................ ................................ ................................ ....... 51 Sampling and Participant Recruitment ................................ ............................. 51 Observation ................................ ................................ ................................ ...... 52 Board of Directors Meeting ................................ ................................ ............... 52 Interviews and Focus Groups ................................ ................................ ........... 52 Data Analysis ................................ ................................ ................................ ... 53 Human Subjects ................................ ................................ ............................... 56 Results ................................ ................................ ................................ .................... 56 Description of Agricultural Practices ................................ ................................ 56 What are the Primary Factors Associated With the Use of Pesticides and How Do They Differ Between Pesticide User and Agroecological Adherents? ................................ ................................ ................................ .... 57 Overview ................................ ................................ ................................ .... 58 Individual ................................ ................................ ................................ .... 58 Interpersonal ................................ ................................ .............................. 59 Economic ................................ ................................ ................................ ... 60 Cultural ................................ ................................ ................................ ...... 63 Political ................................ ................................ ................................ ...... 64 How do Pesticide Users and Agroecological Adh erents Campesinos Differ in their Attitudes and Beliefs Surrounding Pesticide Use? ............................ 65 Attitudes related to pesticide use ................................ ............................... 65 Beli efs associated with pesticide use ................................ ......................... 66 Pesticide Use and exposure? ................................ ................................ ........ 69 Decision making about pesticide use ................................ ......................... 69 Protective equipment ................................ ................................ ................. 70 Discussion and Interpretations ................................ ................................ ................ 71 What Are The Primary Factors Associated With The Use of Pesticides and If They Differ Between Pesticide User and Agroecological Adherents? ........ 71 How Do P esticide Users and Agroecological Adherents Campesinos Differ in Their attitudes and Beliefs Surrounding Pesticide Use? ............................ 73 Pesticide Use and exposure? ................................ ................................ ........ 74 Strengths and Limitations of the Study ................................ ................................ ... 75 Conclusion ................................ ................................ ................................ .............. 76 4 PESTICIDES: SURVEY DEVELOPMENT ................................ .............................. 94 Summary ................................ ................................ ................................ ................ 94 In troductory Remarks ................................ ................................ .............................. 94 Perceptions about Use of Personal Protective Equipment ............................... 97 Perceived Risk and Control ................................ ................................ .............. 98 Knowledge, Attitudes and Beliefs ................................ ................................ ..... 99 The Case of Colombia ................................ ................................ .................... 100 Research Setting ................................ ................................ ................................ .. 102 Methods ................................ ................................ ................................ ................ 102

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8 Participants ................................ ................................ ................................ ..... 102 Sampling and Participant Recruitment ................................ ........................... 103 Cognitive Interviews ................................ ................................ ....................... 103 Board of Directors Meeting ................................ ................................ ............. 104 Que stionnaire Administration ................................ ................................ ......... 104 Data Analysis ................................ ................................ ................................ 105 Human Subjects ................................ ................................ ............................. 106 Results ................................ ................................ ................................ .................. 106 Descriptive ................................ ................................ ................................ ...... 106 Bivariate Analysis ................................ ................................ ........................... 107 Scale Deve lopment ................................ ................................ ........................ 110 Multivariate Analysis ................................ ................................ ....................... 111 Discussion and Interpretations ................................ ................................ .............. 112 Limitations and Strengths of the Study ................................ ................................ 115 Concluding Remarks ................................ ................................ ............................. 116 5 CONCLUSIONS AND FURTHER RESEARCH ................................ .................... 123 Overview of the Study ................................ ................................ ........................... 123 Qualitative Findings ................................ ................................ .............................. 123 Quantitative Findings ................................ ................................ ............................ 125 Strengths and Limitations ................................ ................................ ..................... 126 Future Studies and Public Health Interventions ................................ .................... 127 Policy Implications ................................ ................................ ................................ 131 Summary ................................ ................................ ................................ .............. 132 APPENDIX A INTERVIEW GUIDE ................................ ................................ .............................. 134 B FOCUS GROUP GUIDE ................................ ................................ ....................... 138 C QUESTIONNAIRE ................................ ................................ ................................ 141 D RESEARCH DESIGN AND METHODS ................................ ................................ 146 Overview ................................ ................................ ................................ ............... 146 Approach ................................ ................................ ................................ .............. 147 Research Setting ................................ ................................ ................................ .. 148 Procedure ................................ ................................ ................................ ............. 149 Participants ................................ ................................ ................................ ..... 149 Sampling and Participant Recruitment ................................ ........................... 150 Cognitive Interviews ................................ ................................ ....................... 151 Board of Directors Meeting ................................ ................................ ............. 152 Interviews and Questionnaires ................................ ................................ ....... 152 Data Analysis ................................ ................................ ................................ ........ 154 Overview ................................ ................................ ................................ ........ 154 Qualitative ................................ ................................ ................................ ...... 155

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9 Quantitative ................................ ................................ ................................ .... 157 Human Subjects ................................ ................................ ................................ ... 160 Methods Summary ................................ ................................ ................................ 160 LIST OF REFERENCES ................................ ................................ ............................. 163 BIOGRAPHICAL SKETCH ................................ ................................ .......................... 171

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10 LIST OF TABLES Table page 2 1 Types of comercial pesticides used in Colombia ................................ ................ 41 2 2 ................................ ................ 41 2 3 Summa ry of the main legislation in Colombia related to pesticides .................... 42 3 1 Demographic information of participants ................................ ............................ 78 3 2 Group of particip ants ................................ ................................ .......................... 79 3 3 List of Fungicides used by total sample of campesinos ................................ ...... 79 3 4 List of Herbicides used by total sample of campesinos ................................ ...... 80 3 5 List of insecticides used by total sample of campesinos ................................ ..... 80 3 6 List of chemical Fertilizers used by total sample of campes inos ......................... 81 3 7 List of crops comparing pesticide users with non pesticide users ....................... 82 3 8 List of components of the interpersonal and individual factors ........................... 83 3 9 List of main contextual factors comparing pesticide users with non pesticide users. This is discussed in detail in the results of the first research question. .... 84 3 10 List of protective equipment utilized by campesinos ................................ ........... 85 3 11 List of Beliefs related to pesticide use ................................ ................................ 85 4 1 Frequency of pesticide decision options. ................................ .......................... 119 4 2 Frequency of perceived control to stop pesticide use being 1 no control and 10 maximum control ................................ ................................ ......................... 119 4 3 Frequency of perceived confidence to stop pesticide use being 1 no confidence and 10 maximum confidence. ................................ ........................ 119 4 4 Beta regre ssion procedure for estimating the odds of perceived pesticide harm as a function of variables like age, residence, occupation. ...................... 120 4 5 Logistic regression model for estimating the odds of per ceived pesticide harm as a function of variables like age, residence, occupation. Only age was significant (borderline). ................................ ................................ .............. 120

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11 4 6 Spearman correlation of varia bles 1a to 1n (beliefs and attitudes). The most important correlations are included in this table. ................................ ............... 121 D 1 Agricultural activity in the veredas included in the study. ................................ .. 161 D 2 List of veredas included in the cognitive interviews, individual interviews and focus groups. ................................ ................................ ................................ .... 161 D 3 List of constructs of the study with items used ................................ ................. 162

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12 LIST OF FIGURES Figure page 2 1 Conceptual model including most relevant areas of public health research focused on pesticide use.. ................................ ................................ .................. 44 3 1 Map of Colombia, Antioquia department and municipality of Medellin (red dot). ................................ ................................ ................................ .................... 86 3 2 Shaded relief map of Medellin municipality (see different urban jurisdictions ................................ ................................ ............... 87 3 3 San Cristbal with 17 rural sub divisions (veredas). General cartography and current land use. ................................ ................................ ............................... 88 3 4 Conceptual model of Interpersonal and individual factors related to pesticide use.. ................................ ................................ ................................ .................... 89 3 5 Conceptual model of bel iefs related to pesticide use. ................................ ........ 90 3 6 Conceptual model displaying all the contextual factors and the specific components for each factor described in the text. ................................ .............. 91 3 7 Conceptual model including most influential categories of each factor on ............................... 92 3 8 Conceptual model depicting the factors that influe nce the use of protective equipment.. ................................ ................................ ................................ ......... 93 4 1 Conceptual model describing the most influential individual factors in the decision making process of pesticide use in San Cristobal, Colombia. ............ 122

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13 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy FACTORS RELATED TO THE USE OF SYN THETIC PESTICIDES AMONG AGRICULTURAL RURAL COMMUNITIES IN, COLOMBIA: IMPLICATIONS FOR HUMAN HEALTH, RURAL DEVELOPMENT AND CONSERVATION By Y sabel Polanco August 2012 Chair: Barbara Curbow Major: Public Health Conventional agricultural practices are of ten contrary to human health and environmental conservation. Use of and exposure to pesticides in agricultural communities in tropical countries is a pressing public health problem and an important facet of environmental degradation. This research project was undertaken by documenting use and exposure behaviors among agricultural communities in San Cristobal, Antioquia (Colombia). The research questions were: (1) What are the primary factors associated with the use of pesticides and do those factors diffe r between pesticide users and agroecological adherents ? (2) How do campesino pesticide users and agroecological adherents (non pesticide users) differ in their attitudes and beliefs with regards to pesticide use and exposure? and (3) How do these factors i nfluence I implemented qualitative and quantitative methods in this investigation The qualitative approach was based on community participatory ethnographic research. The latter involved pa rticipant observation, interviews, and focus groups aimed at existing pesticides users and agroecological adherents The quantitative approach used questionnaires to derive

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14 demographic information, scale based evaluations of attitudes and beliefs, pesticid es decision making, perceived confidence, and perceived control. Findings show ed that t he most relevant factors related to pesticide use and their categories include d : a) individual: beliefs, attitudes and knowledge; b) interpersonal: family support and c ultural acceptance of pesticide use; c) economic: fear of living within financially unviable constraints, market conditions and lack of economic support from the government; d) cultural: collective acceptance or tolerance of pesticide use and exposure and onset of negative reactions when stopping pesticide use; e) political: deficient regulations for controlling pesticide use control and adequate utilization of protective equipment. Pesticide users experience d the most apprehension regarding stopping pesti cide use as they often believe d pesticides allow them to obtain better crop yields and, therefore, higher monetary gains. Pesticide users lack ed a positive attitude toward personal protection equipment regardless of the risks to which they may be exposed. Pesticide training was deficient in this population showing a clear need to improve safety conditions and training to reduce occupational hazards. Future studies should explore with greater detail these attitudes and beliefs so as to promote mid to long term public health interventions that directly address the sense of food and income insecurity found among the population of pesticides users, which blocks their transition into a non pesticide scenario for agricultur al production Over the short term, pub lic health programs should continue to educate the population of pesticide users on t he immediate risks of exposure

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15 The decision making process surrounding pesticide use in the studied population was influence d by a variety of factors. Campesinos who we re prone to use pesticides for their crops often exhibited diminished degrees of knowledge about adverse effects of pesticides on human health, believe d pesticides are necessary for their crops, ha d negative attitudes about stopping pesticide use, ha d a st rong family influence toward the use of pesticides, experience d economic fear of stopping pesticide use, cultivate d flowers as their main source of income, express ed strong social acceptance of pesticide use, experience d negative community reactions when a ttempting to stop pesticide use, received government subsidies for pesticide use, and ha d never received any training on the use of required protective equipment. Campesinos who show ed more proclivities towards the use of pesticides were convinced that pe sticides are necessary for their crops as they guarantee substantial yields and larger specimens of the different crop varieties They also exhibit ed low perceived control, low perceived confidence, and a low perception of adverse pesticide effects on huma n health and the natural environment. Future studies are required to fully comprehend the unique occupational health and safety needs of these campesinos. Additionally, future studies should be aimed at designing and introducing long term, well structured public health interventions to increase awareness about the harmfulness of pesticides on human and environmental health so as to promote a well established behavioral change in relation to pesticides use reduction among these communities.

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16 CHAPTER 1 INTRO DUCTION Overview Over the last half century, rural areas of the world have experienced significant changes in land use dynamics including the type of agriculture that is practiced. Since the mid 20th century, the use of many different synthetic pesticides 1 has been management of pests. As a result, farmworkers and campesinos 2 have greatly increased the use of pesticides to manage their crops (Altieri, 2002; Nicholls & Altieri, 1997; Pimentel, 1996; Rigg, 2006; Shiva, 2009). This practice created a new burden for this already vulnerable population, particularly in terms of health risks associated with the handling of pesticides, and also a burden in the direction of th eir technological, economic and food sovereignty, which ultimately affect s human health Pesticide exposure in agricultural communities worldwide is a fundamental public health problem negatively impacting the lives of the millions who directly use such substances and of their families, communities, and the base of natural goods and 1 The term pesticide refers to any synthetic chemical substance intended for preventin g, destroying, repelling, or mitigating pests. Pests can be insects, other animals, weeds, fungi, or microorganisms that cause damage to crops or animals. The term includes insecticides, herbicides, fungicides, and other substances used to control pests M any of these substances are known to have adverse effects on human and ecosystem health because they are designed to kill or otherwise adversely affect living organisms. The term includes Organophosphate, Carbamates, Pyrethroid, and Organochlorine Insectic ides. The definition excludes Biopesticides derived from natural materials such as animals, plants, agroecological practices). Biopesticides are divided into three categories: microbial pesticides (bacterium, fungus, virus or protozoan), biochemical pesticides (non toxic naturally occurring substances such as insect sex pheromones and scented plant extracts), and plant incorporated protectants [sou rce http://www.epa.gov/pesticides/about/]. 2 In this research the term campesino (s) refers to the Spanish word used to describe rural people who mainly do work in agriculture. They are most of the time the owners of the land they cultivate. They can also

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17 services in their localities and beyond (Quandt, Arcury, Austin, & Cabrera, 2001; Restrepo, Muoz, Day, Parra, de Romero et al., 1990; Shiva, 2009). Pesticide use has been ass ociated with many different effect s on human health (Cardenas, 2005; Jimnez & Muoz, 1993; Nivia, 2000) and several environmental alterations ( A ltieri, 2002; Pimentel, 2007). Pesticide use has been associated with many factors includ ing the economic, political, environmental, cultural, interpersonal and individual levels (Salazar, Napolitano, Scherer, & McCauley, 2004; Vaughan & Fridlund Dunton, 2006) The reality of insidious pesticide use is also prevalent in Colombia and yet only a few studies have explored this situation and its ramifications among campesino communities in this geographic region (Cardenas, 2005; Jimnez & Muoz, 1993; Nivia, 2000) This study prov ides new information about the way perceptions of individual, interpersonal, economic, cultural, social, and policy factors are interconnect ed and how those factors influence decision making processes for pesticide use among campesinos established in the agricultural community of San Cristobal, Antioquia, Colombia. C hapter 1 includes the aims of the study, the research questions confronted, and the research methodology and data analysis strategies implemented. Specific Aims Human behavior is complex and different factors at several levels determine it ; not only at the individual level, but also at the social, cultural, economi c, political and environmental levels (Bandura, 2004) Many of these factors, which to a large extent control the decision making process on pesticide use and exposure, need to be properly documented so as to understand their inherent complexity and the context in which they shape campesinos behavior in different communities

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18 The overall goal of this research was to explore and understand why campesinos use pesticides and to identify the f actors associated with this use. These findings were compared with non pesticide user communities (agroecological adherents) in the same geographic area to determine if differences exist and, if so, the characteristics of those specific differences. The s pecific aims for this project were the following: 1) To explore the macro and micro factors (e.g., individual, socioeconomic, and exposure. This was elicited through the impleme ntation of socio ecological and ethnographic community participatory approaches. 2) To compare macro and micro factors between two different campesino communities: a) Community 1, composed of several veredas (rural villages) where agricultural practices a re based on the intensive use of synthetic pesticides, and b) Community 2, encompassing a community that has moved to agroecological practices 3 Broad Research Questions 1) What are the primary factors associated with the use of pesticides and do those fa ctors differ between pesticide user s and agroecological adherents ? 3 Agroecological practices or agroecolog y refer to the application of ecological concepts and principles to the design and managemen t of sustainable agroecosystems It provides the basic ecological principles for how to study, design and manage agroecosystems that are both productive and natural resource conserving, and that are also culturally sensitive, socially just and economically viable (Altieri, 1999). Agroecology goes beyond the use of alternative pract ices to develop agroecosystems with the minimal dependence on high agrochemical and energy inputs, emphasizing complex agricultural systems in which ecological interactions and synergisms between biological components provide the mechanisms for the systems to sponsor their own soil fertility, productivity and crop protection (Altieri, 2002). Agroecology is also the holistic study of agroecosystems, including all environmental and human elements. It focuses on the form, dynamics and functions of their interr elationships and the processes in which they are involved. By understanding these ecological relationships and processes, agroecosystems can be manipulated to improve production and to produce more sustainably, with fewer negative environmental or social i mpacts and fewer external inputs(Altieri, 1999)

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19 2) How do campesino pesticide users and agroecological adherents differ in their attitudes and beliefs with regards to pesticide use? s associated with pesticide use and exposure? Research Purpose The purpose of this research project was to generate useful information that can support a better understanding of the local context in which pesticide use and exposure takes place in agricultu ral communities of San Cristobal and to empower this group of Colombian agricultural campesinos in the decision making process about the use of pesticides. If this information is adequately used in the design of public health programs at the local scale individuals (and their families) in this community may increase their level of awareness relative to the inherent health and environment al risks associated with pesticide use and exposure leading them to work more carefully with these substances, or ultim ately motivating them to migrate to agro ecological practices. Methods I conducted a community participatory ethnographic study with a n ecological approach in the rural division of San Cristobal, Medellin, Colombia. Using snowball techniques, I started wi subdivisions) and used purposive snowball sampling to interview 67 adult campesinos (stratified by user/n on user of pesticides status ). I also conducted focus groups in some of the veredas. T he interviews and focus groups covered general information about the pesticide use, attitudes and beliefs associated with pesticides, and demographic information.

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20 The rese arch strategy I used combined qualitative and quantitative methods. The qualitative approach was based on ethnographic community participatory research, which used participant observation, interviews (67 total), and focus groups (5 total) (Israel et al., 2 005) targeting active adult campesinos from 10 of the 17 rural divisions of San Cristbal, Antioquia, Colombia. These campesinos were pesticide users or agroecological adherents (men and women). I collected and transcribed the i nterviews and focus group in formation S ubsequently I coded the transcripts by themes using the N Vivo software (Richards, 2009; Richards & Morse, 2007) T he quantitative strategy incorporated the collection and analysis of questionnaires (79 total) that included demog raphic information, and questions about beliefs and attitudes through the use of L ikert scales. I conducted s tatistical data processing and analysis using SAS 9.2. Concurrent mixed methods of analysis of qualitative and quantitative data helped to identif y useful factors for creating future research projects and future public health interventions. The methodology here delineated has rarely been implemented in Colombia. A d etailed description of the methodology used in this study is in Appendix D. Discussio n and Conceptualization of the Problem Reducing pesticide use and exposure can significantly improve the quality of life of peasant communities. However, a reduction in pesticide use and exposure implies behavioral changes of agriculturalists who often wor k with th ese chemical compounds. In turn, behavioral change is associated with different factors including cultural, economic, political, environmental, interpersonal and individual. Many theoretical frameworks have been developed for studying and explaini ng changes in health related behaviors (Glantz et al, 1997). These frameworks range from the individual to community and societal levels (Glantz et al, 1997). Recent research has incorporate d

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21 the multiplicity of influences on behavior in a developing appro ach known as t he Ecological Model (Bronfenbrenner, 1977; Edberg, 2007) Under this approach it is interaction between an individual and the environment is a process that influences behavior (Edberg, 2007) I used the ecological model of human health behaviors (Bronfenbrenner, 1977; Edberg, 2007) to guide the present study. This model includes the following factors that influence behaviors: Individual: beliefs, knowledge, perceptions. Socio cultural factors: lifestyle patterns, attitudes and beliefs, level of social support. Socioeconomic and structural: poverty, education, access to health care and prevention services, social stressors such as: civil strife, neighborhood violence, racial and other discrimination. Political: agricultural and health policies, funding for health promotion programs, health insurance, and regulations that impact health risk. Environmental: air, soil, animal and water pollution. This research explore d in more detail the factors related to pesticide use among a specific campesino community in San Cristobal. The study was founded on the need of in ide use and exposure from a more holistic point of view. Overview of Chapters In this C hapter I introduce d the study by briefly delineating the situation of pesticide use in the world and the alterations associated with this use and exposure including human health and environmental alteration. I defin ed the aims of the project, the research questions, the methodology and the theoretical model that guided the

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22 study In C hapter 2 I review the literature related to pesticide use in the world, in Colombia and t he human health effects associated with pesticide use and exposure In Chapter 3 I present and discuss the results associated with individual interpersonal and contextual factors (social, cultural, political, and economic ) associated with pesticide use fr om the qualitative perspective. In Chapter 4 I discuss the factors at the individual level (attitudes, believes, control and confidence) related to pesticide use and the decision making process from the quantitative perspective. As a final section, in C hap ter 5 I contextualize all of the findings so as to reach more generalized conclusions and outline future directions for this field of research. Appendices A, B, and C contain the instruments utilized in the study and Appendix D describes in detail the meth ods of the study. Summary Pesticide use in the world constitutes a major public health problem. Unfortunately, Colombia like many developing countries with agricultural economies and a blur red legal framework to control the introduction, commercializatio n, distribution, manufacturing and utilization of these hazardous chemicals is not exempt to this situation. This study explore d the factors related to pesticide use and exposure among individuals in a campesino community located in San Cristobal, Colomb ia. The study aims at holistically understanding these factors and comparing the reasons that force some campesinos to use pesticides while others have transitioned to agroecological practices in pursu it of greater economic, health and food sovereignty T his was elicited through a combination of qualitative methods, with the implementation of the ecological model ethnographic community participatory approaches, and quantitative methods

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23 utilizing scales of attitudes, beliefs, self efficacy and perceived co ntrol related to pesticide use and exposure

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24 CHAPTER 2 LITERATURE REVIEW Introduct ory Remarks During the last 60 years the vast majority of rural areas worldwide have gone through marked modifications in land use dynamics, particularly with regards to the forms of agriculture that are put into practice. Since the 1950s the use of a wide range of pesticides has been introduced as the norm for many agricultural practices ( Rigg, 2006; Shiva, 2009 ) During this time frame many campesino communities have greatl y increased the use of pesticides to manage their crops ( Altieri, 2002; Nicholls & Altieri, 1997; Pimentel, 1996; Rigg, 2006; Shi va, 2009) This practice created a new burden for this population, manifested by an assortment of negative impacts on the communities deriving from both health risks associated with the handling of pesticides and environmental degradation linked to pestic ide use and its dispersal th r ough terrestrial and aquatic ecosystems (Pimentel et al., 2007) Colombia is not exempt to these pesticide related alterations because the country ranks among one of the most important agricultural territories in Latin America, which implies an extensive use of pesticides and lax regulations (MinisteriodeSalud, 2010) The main objective of C hapter 2 is to review the literature to better understand public health problem s attributable to pesticide use in the world and more specifically in Colombia. In t he first section I review the situation of pesticide use and exposure worldwide, and in Colombia. In t he second section I review the health effects related to pesticide use and exposure In the last section I discuss, based on this literature review, recommendations for the direction of future studies

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25 Pesticide Use as an Important Public Health Issue in the World Multiple economic, political, social and environmental factors determine pesticide use for agricultural practices worldwide. Developing countries, which often face complex, disadvantageous socio economic and political frame works tend to be more vulnerable to the imposition of agricultural models that involve the extensive use of pesticides ( Altieri & Nicholls, 2008; Pimentel, 2007) Such impositions frequently deri ve from the control exerted by multinational agrochemical businesses on weak governments through lobbying and other common practices in the context of corporate democracies (Shiva, 2009) leaving little or no room for participation i n the decision making process of those more directly affected by pesticide use and exposure i.e., farmworkers and campesinos (London, 2002) Pesticide exposure of farmworkers and their families in developing countries is aggravated by economic policy changes related to structural adjustments programs, a g lobalized economy, and violations of their rights, which underlie much of their burden of ill health (London, 2002, 2003) Women, particularly in the agricultural sector, are increasingly exposed because they are concentrated in the most marginal positions in the formal and informal workforces (London, 2002; Sanmiguel Valderrama, 2007; Shiva, 2009) Types of S ynthetic P esticide s in the W orld Many types of pesticides are manufactured today. Their effects on human health are strictly related to the specific chemical compound found in each pesticide type. Within the broad family of synthetic pesticides, subgroups are defined accord ing to the type of pest they are intended to eradicate: insecticides (used against insects and

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26 arachnids), herbicides (used against plant pests commonly called weeds), fungicides (used to control fungi), and rodenticides (used to kill rodents) (Maxwell, 2009) The first generation of synthetic organic insecticides was the group of o rganochlorine insecticides. The best known chemical in this group is dichloro diphenyl trichl oroethane also known as DDT. During World War II, DDT was widely used by the US military to protect troops against disease. After the war, DDT was sprayed in communities to control disease and sprayed in fields to kill agricultural pests (Maxwell, 2009) Some of these insecticides include: chlordane, aldrin, dieldrin, and heptachlor. Organochlorine pesticides are nerve toxins: they disrupt the central nervous system, causing convulsions, and death (Schiavonea, Kannanb, Horiib, Focardia, & Corsolinia, 2010) However, their acute toxicity to people is very low, and for this reason it was many years before the y were considered a human health problem. These chemicals are persistent in the environment, are lipophilic (Schiavonea et al., 2010) bioaccumulate in fatty tissue, and biomagnify in th e food chain (Maxwell, 2009) The second generation of synthetic organic insecticides was the group of o rganophosphates, originally developed as nerve gases to be used in war (Maxwell, 2009) T he o rganophosphates disrupt the central nervous system, inhibiting an important neurotransmissor called cholinesterase, causing convulsions and death at high doses. However, these chemicals are not persistent in the environment. Their acute toxicity varies greatly (e.g. p arathion is highly toxic to humans whereas m alathion is much less toxic ) (Maxwell, 2009) Organophosphates were promptly followed by c arbamates, which have a similar chemical action, but low short term toxicity in humans. Most recently, synthetic

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27 insecticides called p yrethroids have been developed; this group includes p ermethrin and r esmethrin. These pesticides have low toxicity to humans and are used in some household products, mosquito repellents, and head lice treatments (Maxwell, 2009) Synthetic herbicides have a broad range of chemical structures with considerable overlap in toxic effects, and thus it is simpler to distinguish these chemicals by their effects on different types of plants. Herbicides can be selective (kill broad leaved plant species, but not plants in the grass family e.g. a trazine) and non selective (destroys all types of plants, e.g. r oundup) (Maxwell, 2009) Fungici des are also critical in the protection of some crops grown in wet conditions (Maxwell, 2009) Pesticide Utilization and Effects Pesticides have been widely used in the wo rld mainly to control pest s in agriculture (Bills & Gross, 2 005; Carson, 2002; Gomiero, Paoletti, & Pimentel, 2008; Harrison, 2011; Jorgenson & Kuykendall, 2008) Agricultural production is usually associated with a philosophical foundation that entails a distorted emphasis on yield, which in turn promotes an ove rsimplified view of ecosystem functioning, leading to an abuse of agrochemical inputs (synthetic pesticides and fertilizers) (Banks, 2004; Nicholls & Altieri, 1997; Shiva, 2009) Up to 90% of the deleterious chemical substances in pesticides miss their targets (insec ts, fungi, weeds, etc.) and end up in the environment creating ecological disequilibrium and posing a serious threat to human and ecosystem health (Pimentel, 1996; Pimentel & Edwards, 1982; Pimentel et al., 1997; Restrepo, Muoz, Day, Parra, Hernandez et al., 1990) T he types of pesticides used in each country depend on the specific laws and regulations existing in each place. While some pesticide formulation and production does occur at the local level, many developing countries, must rely on importing most of

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28 their chemically based pest control products from industrialized countries (MinisteriodeSalud, 2010) A number of nations, especially developing countries, have not enacted legislation to govern the importation, domestic use and disposal of these pesticide materials (Cardenas, 2005; Sneldera, Masipiqueab, & de Snooa, 2008; Williamson, Ballb, & Prettyc, 2008; Yassin, Abu Mourad, & Safi, 2002) In some countries in East Asia, a broad spectrum of pesticides is freely sold in stores or markets. (Sneldera et al., 2008) Some of the pesticides used in the Middle East, hav e been suspended, banned, or cancelled in other countries because of their mutagenicity, teratogenicity, or carcinogenicity (Yassin et al., 2002) Even with an established legal framework, governments in many developing countries frequently lack the infrastructures required to enforce laws (Castro, 2003) In such countries, the growing use of pesticides is influenced by government subsidies, which lower the costs of supplying pesticides to local farmers and campesinos (A ltieri, 1992; Cardenas, 2005; Williamson et al., 2008) Another promoter of pesticide use is market pressure s on export agriculture from developed countries into developing countries (Costanza et al., 1998; Murray, 1994; Sneldera et al., 2008) Pesticide debates and trends in Europe an markets are clearly influencing pesticide practice in African export horticulture (Williamson et al., 2008) In Latin America, the export economy mainly from the United States influences agricultural practices and pesticide use (ICA ANDI, 1997; Murray, 1994; Pimentel, 2007) In East Asian countries,

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29 agriculturalists also experience market pressure that pushes them into pesticide use for their crop production (Sneldera et al., 2008) A variety of crops are sprayed with pesticides. In East Asia, e.g., The Phi lippines crops such as rice and corn are routinely sprayed with pesticides (S neldera et al., 2008) Major crops grown in several middle eastern countries and surrounding geographic areas that are the target of pesticide treatment include citrus fruits, olives, almonds, grapes, other subtropical fruits, vegetables, and flowers. Mor e than 250 metric tons of formulated pesticides, mainly insecticides and fungicides, in addition to one thousand metric tons of methyl bromide, are used annually in this geographic region (Yassin et al., 2002) Even though pesticides in Africa are applied in lower quantities than in Asia and Latin A merica, their use is still significant (Williams on et al., 2008) In some African countries including Benin, Ethiopia, Ghana and Senegal, pesticides tend to be used most intensively on cash crops, especially cotton, cocoa, oil palm, coffee and vegetables. These crops are cultivated mainly for export a nd local markets (Williamson et al., 2008) Fo r Latin America figures are equally staggering. In the 1990s, in El Salvador and Guatemala, 75% of the total pesticide consumption was devoted to cotton ( Altieri, 2002) Apple and pear orchards still receive up to 8 16 treatments per season in the southern cone countries (Chile, Argentina, Uruguay, Southern Brazil), and most fruit trees in t he subtropical and tropical countries are routinely sprayed for protection against fruit flies. Among the vegetable crops, tomatoes and potatoes by far account for the greatest pesticide use (Castro, 2003; Maltby, 1980)

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30 Pesticide Use in Colombia Colombia is an important agricultural country producing a great variety of crops for local consumption and also for exportation. Utilization of pesticide s is pervas ive in (Cardenas, 2005; Minister io_de_Agricultura, 2011) Regulations for pesticide use have banned certain pesticides but many others that are very toxic are still heavily used by agricultural communities and agribusiness alike (Cardenas, 2005) In the context of blur red regulatory measures to control pesticide use pesticides represent a sustained threat to hu man health and the natural environment ( Altieri & Nicholls, 2008; Pimentel et al., 2007) Types of Pes ticides use in Colombia In Colombia, pesticides have been extensively used to control not only agricultural pests, but also different vectors, e.g., insects, that contribute to the spread of different endemic diseases in humans including malaria, leshmania sis, and chagas (Castro, 2003; Ministerio de Salud, 2010). As a measure to controlling dis ease vectors, pesticides have contributed greatly to reduc ing morbidity and mortality in many regions of the country (MinisteriodeSalud, 2010) Pesticides were first imported to Colombia in 1962. Colombia exported approximately 17,000 T of dry and 4 ML of liquid pesticides each year in the 1990s (MinisteriodeSalud, 2010) In 2010, there were 95 companies registered to produce and sell pesticides in Colombia, of which 25 were part of multinational corporations and 73 were locally owned companies, including flower, tobacco, palm, and banana farmers who import pesticides directly (MinisteriodeSalud, 2010) Pestic ide use in agriculture is more prevalent in certain crops. Up to 70% of all pesticide use in Colombia is applied to rice, cotton, potatoes, pastures for cattle grazing, and flowers (Castro, 2003) The types

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31 of pesticides most commonly used are herbicides and insecticides (Table 2 1 ). The first 12 Persistent Organic Pollutants provided in the convention of Stockholm were (Valsaraj & Thibodeaux, 2010) Their compounds names are: DDT, aldrin, dieldrin, endrin, heptachlor, chlordane, toxaphene, mirex, HCB, Polychlorinated Biphenyl also known as PCBs, and Dioxins (polychlorinated dibenzo dioxins and polychlorinated diben zofurans). They are in the category of environmental endocrine disrupting chemicals (Valsaraj & Thibodeaux, 2010) Some of the pesticides (Valsaraj & Thibodeaux, 2010) are still being used in Colombia (Table 2 2 ). The four toxicologic categories in Colombia are: Category I: extremely toxic (fatal if ingested and highly corrosive to eyes and skin) ; Category II: highly toxic; Category III: medium toxic; and Category IV: slightly toxic (SENA, 2008) These categories known as signal words on the pesticide package and are assigned on the basis of the highes t measured toxicity, be it oral, dermal, or inhalation; effects on the eyes and external injury to the skin. Since the toxicity category and signal words are based on the total formulation, certain products may have the same active ingredient (a.i.) but ma y bear different signal words in different formulations. Signal words indicate the relative toxicity of a pesticide formulation. This is important because pesticide users should always read the pesticide label to determine what personal protective equipmen t (PPE) is required to wear for that specific product (MSU, 2012). Relevant Pesticide Regulations in Colombia The regulation of pesticides in Colombia has focused on direct regulatory standards, also called command and control by the state, which to some extent have followed similar decisions made in other countries, such as the United States.

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32 However, in Colombia there is not the same capacity for regulation and control (Cardenas, 2005) This is due to several factors: a) a large number of rules must be enforced by many institutions; b) scarce technical and logistical resources; c) lack of coordination; d) lack of knowledge about the specificity of standards ; and e) poor enforcement at the regional and local levels. The last has worsened since the 19 90's, when implementation of governmental decentralization began in the country; a situation that has entailed, among other things, the transfer of law enforcement from central to local offices (Cardenas, 2005) Delegated by the Ministry of Agriculture and Rural Development, and in accordance with Resolution 3079 of 1995, the Instituto Colombiano Agropecuario (ICA, Colombian Agricultural Institute) retains techn ical control of agricultural supplies sold in the country through the registration of producers. The ICA authorizes imports of finished products and raw materials used as inputs in agricultural production. It also approves the export and import of pesticid es, regulates laboratory standards for quality control of products and records sales of products to market (Cardenas, 2005) In 1991, the Ministry of Health issued Decree No. 1843 of July 22 to further regulate the use and management of pesticides in Colombia. This constitutes the most important piece of legislation in this realm u p to date (INVIMA, 1991) and it includes guidelines for: a) e stablis hing the National Pesticides Toxicological Classification and issuing permits for pesticide experimentation and development within Colombia ; b) r egulating the production, processing, formulation, storage, transportation, distribution, commercialization and application of pesticides ; c ) i ssuing health licenses, registrations, permits and concepts associated to the use and handling of pesticides ; d ) p ackaging

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33 and labeling of containers for the disposal of pesticide waste and residues ; e ) b uilding sanitation f or medical care and supervision ; f ) p ersonnel training on human environment protection protocols for pesticides use ; g ) a dequate advertising of pesticide products ; and h) e pidemiological surveillance and health monitoring of pesticides and health measures, sanctions and procedures for pesticides in question. This decree seeks to maintain a dynamic integration between the ICA, the ministries of Agriculture and Social Protection, industry, and users that would foster systematic study of pesticides in Colomb ia and adequate design/execution of health programs to address the problems associated with pesticide use and exposure (Cardenas, 2005 115) At present, several government ministries in Colombia, namely Agriculture, Public Health, and Environment, have advanced official programs to improve the management of and conditions for the use and handling of pesticides in an effort to diminish the dangerous effects of these products (Castro 2003) This development has led the Colombian government to create new legislation on pesticides. The basic Colombian regulations related to the use, handling and disposal of pesticides include: 1) Decree 843 of 1969 ; 2) The natural sanitary Code of 19 74 ; 3) The National Sanitary Code of 1979 ; and 4) Decree 1843 of 1991 (Castro, 2003) ( Table 2 3 ) In ad dition to the previous regulations, between 1974 and 1993 the ICA and other governmental agencies prohibited or restricted the production, importation, trade, or use of 21 pesticides including e thylen d obromide o rganochlorine (DDT, Endrin, chlordane, ald rin, heptachlor, diendrin, camphechlor), paraquat (prohibits aerial application), and parathion (restricted to cotton) (Cardenas, 2005; Castro, 2003)

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34 In Colombia, the Law 99 of 1993 was created by the Ministry of En vironment and the National Environmental System. This law led to the requirement of conduct ing environmental impact studies as basic tools for making decisions about activities that sign ificantly affect the natural environment. It also led to the requireme nt to incorporate environmental costs using economic instruments for the prevention, correction and restoration of environmental degradation and the conservation of renewable natural resources (Cardenas, 2005) The same law enacted the precautionary principle, which states that the formulation of environmental policies takes into a ccount the outcome of the scientific research process and when there exists danger of serious or irreversible damage and / or lack of full scientific certainty, the product should not be used as a reason for postponing cost effective measures to prevent envi ronmental degradation (Cardenas, 2005) T he Ministry of the Environment has a s one of its functions the ability to issue environmental permits for the importation and production of pesticides, taking into account environmental impact studies. It is also responsible for regulating the location of production plants and it is the coor dinating body for environmental policies related to pesticides (Cardenas, 2005 ) .The variety of regulations mentioned above help to understand the legal framework that partially defines the use of pesticides in Colombia. Effects of Pesticide Use and Exposure on Human Health Agricultural workers are regularly exposed to synthetic pes ticides that have detrimental effects on the health of humans and other animals (Ar cury, Quandt, & Russel, 2002; Quandt, Arcury, Austin, & Cabrera, 2001) Stud ies from occupational groups link excess morbidity and mortality in humans to pesticide exposure (Maxwell, 2009; Ott, Steinemann, & Wallace, 2007) A variety of human systems can be affected,

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35 including neurological, immunological, respiratory and reproductive (Ott et al., 2007; Rothlein et al., 2006) Several potential means of exposure exist. Ingestion of concentrated pesticides and inhalation of vapors have been reported (Ott et al., 2007; Vergara, 2000) However transdermal exposure seems to be the most common and significant exposure route for agricultural workers (Ott et al., 2007) The greatest risk and hig hest toxicity is linked to skin contact with concentrated pesticides during mixing and application (Ott et al., 20 07) Exposure not only affects the farmworker directly involved in the manipulation of these toxic substances but also other more vulnerable household members such as children and pregnant women (Freeman, 2007; Guillette, Meza, Aquilar, Soto, & Enedina, 1998; Nivia, 2000; Shalat et al., 2003) Pesticides and the tools of the trade are usually carrie d by the farmworker and other family members and many pesticide residues are inadvertently brought into their homes or obliviously stored in accessible areas of the house (Freeman et al., 2004; Shalat et al., 2003) Studies have found reproductive alterations and congenital malformations related to in ute ro exposure to pesticides (Colborn, Dumanoski, & Myers, 1996) Apparently some environmental factors might influence the declination of the age at which female breast development begins. These fac tors include interactions between genetic makeup, nutrition, and possible cumulative exposure to estrogens, both endogenous as well as environmental beginning during in utero development (e.g., endocrine disruptor o rganochlorine pesticides ). A study exami ned the onset of breast development in a group of peripubertal girls from the Yaqui Valley of Sonora, Mexico. Researchers observed that girls from valley towns, areas using modern agricultural practices, exhibited larger

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36 breast fields than those of girls l iving in the foothills who exhibited similar stature (e.g., weight, height, and body mass index), and genetic background. Girls from valley towns displayed a poorly defined relationship between breast size and mammary gland development, whereas girls from the Yaqui foothills, where modern agricultural practices are absent, showed a robust positive relationship between breast size and mammary size. Mammary tissue, determined by palpation, was absent in 18.5% of the girls living in agricultural areas, althou gh palpable breast adipose tissue was present. No relationship was found between mammary diameter and weig ht or BMI in either population (Guillette et al., 2006) In the particular case of children, studies have found cognitive, neurologic, and developmental alterations (Freeman, 2007; Guillette et al., 1998; Rothlein et al.) A major route of exposure in c hildren is the non dietary ingestion of pesticides as a result of mouthing behavior (Freeman, 2007; Shalat et al., 2003) Due to the variety of sources that affect environmental exposur e to pesticides, mainly the residential exposure of children, some studies have measured the amount of organophosphates (OP) pesticides rinses finding residues, and OP metabolites in urine samples and finding up to 13 different metabolit es above detectable levels (Bravo, Driskell Whitehead, Needham, & Barr, 2002; Cullen, Schmink, Valladares Padua, & Morato, 2001; Freeman et al., 2004; Shalat et al., 2003) Other investigations have shown that children who live in agricultural comm unities had higher amounts of pesticide metabolites in their urine than children who resided in non agricultural communities (Freeman e t al., 2004; Lu, Fenske, Simcox, & Kalman, 2000; Shalat et al., 2003)

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37 Prevalence of pesticide use and exposure been reported in the literature (Cardenas, 2005; Hoyos et al., 1996) A study in Cundinamarca, Colombia, showed moderate increases in the prevalence rates of spontaneous abortion, prematurity, stillbirths and congenital malformations for hemangioma was also detected among children born in this population (Restrepo, Muoz, Day, Parra, de Romero et al., 1990; Restrepo, Muoz, Day, Parra, Hernandez et al., 1990) Low cholinesterase levels, as a consequence of pesticide use such as organophosphates and carbamates, were found in agricultural commun ities in Bolivar and Cordoba, Colombia, between 1996 and 1997 (Silva, Morales, & Ortiz, 2000) Another st udy performed in San Cristobal, Colombia also showed altered blood cholinesterase levels among campesino adult population (Jimnez & Muoz, 1993) In Palmira, Colombia, a renowned agricultural province, research showed altered blood cholinest erase levels in 22% of the samples of the general campesino population, including all ages. In the specific case of children, 16% of girls and 21% of boys had altered levels. L ow choli nesterase levels were found in 64% of exposed females and in 45% of ex posed males, indicating that active exposure to organophosphate pesticides act as cholinesterase inhibitors (Nivia, 2000) These alterations can cause chronic neuromotor and neurodevelopment retardation especially in children (Freeman, 2007; Guillette et al., 1998; Ott et al., 2007) .Other health effects including renal and liver damage among male and female agricultural workers, were found in the population sampled in the study. High rates of spontaneous abortion, congenital malformations and stillbirths were also found in the study population (Nivia, 2000) All this information

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38 indicates that pesticide use in Colombia is persistent and it deserves more research to better understand the dimensions of the problem Recommenda tion for Future Research M ore research is needed in different areas of public health in order to perform a better assessment of the pesticide health related problems in this population In the area of epidemiology, it is important to explore morbidity and mortality of different health effects associated with pesticide use ( Guillette et al., 1998; Nivia, 2000) Only a few studies in Colombia have explored the deleterious effects of pesticide use and exposure on human health among agricultural populations. Preliminary findings stress the variety and severity of different health alterations among men, women, and children including a hig h prevalence of low cholinesterase levels still births, high abortion rates, birth defects, and neurologic alterations among children (Jimnez & Muoz, 1993; Nivia, 2000; Restrepo, Munoz et al., 1990; Restrepo, Muoz, Day, Parra, Hernandez et al., 1990) Future in depth studies in peri pubertal girls should evaluate if breast de velopment is altered and should examin e mammary tissue growth and fat deposition in breast tissue if we want to understand environmental influences on the breast development phenomena in this population. In the policy area m ore research is needed to find out what factors are needed to enforce the use of protective equipment This should include advocacy and behavior change interventions targeting decision makers with the aim of improving regulations and better enforcement for pesticide use. In the area of behavioral sciences more research should be done in this topic using the ecological model (Bronfenbrenner, 1977) to better understand the individual,

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39 interpersonal, socio cultural, eco nomic, political and environmental factors that influence the pesticide use decision making process of these campesino communities In the area of environmental health more research on exposure analysis (Ott et al., 2007) should be done exploring and measu ring dermal, eye, oral, and respiratory exposure of campesinos during and after the pesticide applications, especially considering PPE is deficient in this population and occupation hazards are high (Nivia, 2000). Future research should also measure pestic ide residues on water, air, soil, and food, considering this ultimately affects human health. This interdisciplinary work in public health research is needed so that various approaches can contribute to a thorough understanding of the inherent complexities of the pesticide use problem Such an approach presents an interesting opportunity and a major challenge for the academic community in related fields. It also provides a better understanding of the complex problem of pesticide use in San Cristobal. This i nterdisciplinary work should also be implemented in different regions of Colombia and also in Latin America where pesticide use is prevalent with disastrous and costly (economic and moral) consequences for human health and the environment. I present a con ceptual model of this interdisciplinary research in Figure 2 1. Summary Pesticides use is prevalent in many areas of the world contributing to different human health alterations and environmental degradation. This use of pesticides is a serious public heal th problem affecting hundreds of millions of individuals of all ages including children, women in childbearing ages, adults and the elderly. When individual s spray/ appl y pesticides in the workplace, in a parcel of land either owned by them or by a company, they are affecting their own health and hence their full potential as a member

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40 in society, but it is also affecting, directly and indirectly their family, neighbors and consumers through the contamination of food stuffs, soils, water, and air. Environment al degradation caused by pesticide use pushes the peasant into a vicious circle of increased agrochemical dependence which will ultimately translate into the deterioration of health in the community at the individual and collect ive levels. In other words, the pursu it of human health through the reduction in pesticide use is integral to environmental conservation and vice versa Pesticide use in Colombia is both common and complex. High amounts of pesticides are use d every year in different crops and the r egulations of this use are scant and hard to enforce (Cardenas, 2005) Only a few studies have explored the myriad of negative health effects associated with pesticide use and exposure (Jimnez & Muoz, 1993; Nivia, 2000; Restrepo, Muoz, Day, Parra, de Romero et al., 1990; Restrepo, Muoz, Day, Parra, Hernandez et al., 1990)

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41 Table 2 1 Types of commercial pesticides used in Colombia Pesticide type % used Biologic or naturals 5% Insecticides 30% Herbicides 35% Fungicides 23% Coadjuvants 3% Physiologic regulations 3% Rodenticides 1% Total 100% Source: (ICA, 1999) Table 2 2 Colombia Pesticide Year 1991 Year 2004 1. a ldicarb Free Free 2. c anfeclore Restricted Prohibited 3a. c lordane Restricted Prohibited 3b. h eptaclore Prohibited Prohibited 4. c lordimeform Prohibited Prohibited 5a. d ibromocloropropane. Prohibited Prohibi ted 5b. e tilendibromur. Prohibited Prohibited 6a. a ldrn. Prohibited Prohibited 6b. d ieldrn. Prohibited Prohibited 6c. e ndrn. Prohibited Prohibited 7a. HCH/BHC. Free Prohibited 7b. l indano Free Prohibited 8. DDT Restricted Prohibited 9. p araquat Free Prohibited in aerial spraying 10a. p aration Free Restricted 10b. m etil paration Free Restricted 11. p entaclorophenol Free Prohibited 12. 2,4,5, T (Triclorofenil) Prohibited Prohibited Source: (Cardenas, 2005)

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42 Table 2 3 Summary of the main legislation in Colombia related to pesticides Decree Function 1) Decree 843 of 1969 Regulates agricultural consumables and describes the area of action and responsibility for the agricultural and health sectors. Anyone who participates in the production, importation, or use of fertilizers, pesticides or drugs for agricultural pur posed must register with the ICA. (2) The natural sanitary Code of 1974 Outlines the general criteria for protection of renewable natural resources and the environment. (3) The National Sanitary Code of 1979 Established in a general way that the import manufacture, storage, transport, commerce, handling, or disposal of dangerous substances should be handled with the necessary precautions to avoid damage to human, animal, or environmental health. (4) Decree 1843 of 1991 Adopted and integrated the recom mendations of the Food and Agriculture Organization of the United nations (FAO} Code of Conduct and International Sanitary Rules, in conjunction with Resolution 992 of the ICA, constitute the basic rules for epidemiological surveillance and integrated mana gement by officials of the agriculture, public health and environmental ministries of the registration, use, and handling of pesticides. It specifies control for agriculture, health and environmental activities related to pesticides; and establishes the co ncept of providing toxicological data as a requirement for obtaining trade (sale) licenses from the ICA. Source: (Cardenas, 2005)

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43

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44 Figure 2 1 Conceptual model including most relevant areas of public health research focused on pesticide use. More re search is needed in this areas of public health: epidemiology, policy, behavioral sciences, and environmental health.

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45 CHAPTER 3 A QUALITATIVE ANALYS IS OF COLOMBIAN CAMP CIDES: CONTEXTUAL, INTERPER SONAL AND INDIVIDUAL FACTORS Summary C olombian agricultural campesinos constitute a vulnerable and understudied population. They are at high risk of exposure to occupational hazards including pesticide exposure. Adverse health effects associated with this exposure have been reported in the lit erature making for a critical public health problem. The present study implemented an ecological framework for exploring factors at different levels, including individual, interpersonal, cultural, economic and political, that influence pesticide use and ex posure among peasant communities of pesticide users and non users in San Cristobal, Antioquia, Colombia. Data production for this study involved 67 individual interviews and 5 focus group discussions with adult rural agricultural campesinos, males and fe males. Participant observation and community participation were also used as part of the methodology. Factors that influence pesticide use and exposure differ ed between campesinos who are assiduous pesticide users and those who have reduced or stopped pest icide use and mov ed to agroecological practices. Educational interventions should target family support and safety measures. Increased attention to economic opportunities and technical support in the agricultural sector, culturally specific education inter ventions to address cultural barriers to reducing pesticide use, and intensive safety training for campesinos are recommended approaches for addressing pesticide exposure. Introduct ory Remarks Synthetic pesticides are widely used in modern agricultural pr actices, in fact they have been increasingly used since their introduction in the 1950s (Carson, 2002)

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46 Pesticides are associated with major and adverse health and environmental effects in different parts of the world (Castro, 2003; Freeman, 200 7; Guillette et al., 1998; Nivia, 2000) Health effects of pesticides can be immediate, e.g., rashes, headaches, nausea, vomiting, shock, disorientatio n, respiratory failure, coma, and death (Reigart & Roberts, 1999) Long term health effects related to pesticide exposure including cancer, and neurologic and reproductive problems have also been documented (Nivia, 2000; Restrepo, Muoz, Day, Parra, Hernandez et al., 1990) The severity a nd pervasiveness of the deleterious health effects associated with pesticide exposure make it a major, global public health problem (Carson, 2002) Agricultural production is one of the major economic sectors in Colombia. Use of pesticides is prevalent at both large and small scale production facilities (Pimentel, 2007) Agricultural populations in Colombia are potentially exposed to pesticides and are particularly vulnerable to concomitant health pr oblems. They are likely to experienc e occupational hazards (Fleming & Herzstein, 1997) Campesinos in Colombia live under economic struggle s because of market pressures and lack of government support (Cardenas, 2005; Nivia, 2000) The Colombian agricultural population lives marginalized and under minimal working safety conditions and education al op portunities (Nivia, 2000; Sanmiguel Valderrama, 2007) A small number of studies have examine d the multitude of social, cultural, organizational, and other external factors that have the potential to affect the health and safety of this agricultural population (Salazar et al., 2004; Sanmiguel Valderrama, 2007) Most studies concur that the decision making process that campesinos confront in deciding whether t o use pesticides is an intricate one; not necessarily controlled by

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47 the degree of knowledge about pesticide harmfulness and deeply influenced by individual, interpersonal, soci o cultural, economic and political factors (Harrison, 2011; London, 2003; Salazar et al., 2004) Documented insight into the work lives of campesinos in t his geographic region are limited (Nivia, 2000) Few studies in Colombia have explored the factor s that influence and predict health related behaviors associated with pesticide use and exposure from a holistic or ecological perspective (Cardenas, 2005; Sanmiguel Valderrama, 2007) A critical need exist s to unders tand the unique work experiences and perceptions of campesinos in Colombia as a way to identify the full range of factors that influence pesticide use and exposure and affect their ability to protect themselves from workplace hazards (Cas tro, 2003; Nivia, 2000) Study Aims and Research Questions This study was guided by the ecological framework from a qualitative perspective with the aim of: 1) e xploring individual, interpersonal, socio cultural, economic, political and environmental fac pesticide use and exposure ; and 2) c omparing all these factors between a pesticide user and non user agricultural campesino populations. The following research questions were defined for this stud y: 1) w hat are the primary factors associated with the use of pesticides and, do they differ between pesticide user and non user? 2) h ow do campesino pesticide users and agroecological adherents differ in their attitudes and beliefs surrounding pesticide use? 3) h ow do these factors influence campesino s use and exposure ?

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48 Contextual Information of the Research Setting Colombia is a tropical country in North Western South America (Figure 3 1), with a long agricultural t radition dating back to pre Columbian times (Medellin, 2010) The Department of Antioquia, in the Andean region, has a significant share in the bulk of agricultural p roduction in Colombia. San Cristobal, at the heart of the Department of Antioquia, is one of the five Corregimientos (Rural Division s ) within the jurisdiction of 2). The head of the township is situated 11 miles from dow ntown Medellin. San Cristbal encompasses the head of the township and 17 veredas (Rural Sub divisions) (Figure 3 3) (Medellin, 2010) The veredas included in the st udy were : El Patio, El Llano, Las Playas, La Cuchilla, La Palma, El Carmelo, Travesas, Yolombo, El Uvito, and San Jos de la Montaa. The community in San Cristobal is characterized by a well established predominant population that has inhabited the r egion for several generations In the year 200 9 the population in San Cristobal was estimated at ~3 6 ,000 inhabitants (1 7 ,974 males and 17,903 females) (Medellin, 2010 ) Land tenancy in this community is marked by small landholders who now possess the piece of land that has been passe d generation after generation. M ost inhabitants in the veredas own their small farms with an average extension of 1.5 acre s in which they carry out agriculture and sometimes also have poultry production (Medellin, 2010) Agriculture constitutes the main economic activity in San Cristbal and this r ura l d ivision ranks as the largest horticultural district of Medellin T he different land uses of each rural sub division are presented in Figure 3 3 (Medellin, 2010) C ommercialization of crops produced in San Cristobal is channeled through two different markets: 1) a conventional large produce distribution scheme operated at Plaza Minorista, Plaza

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49 Mayorista and the Plaza de Flores; and 2) s mall, local, fair trade organi c markets (only connected with convoluted networks of intermediaries and big supermarket chains that are economically powerful and that regulate crop types and prices; an d this is where the bulk of profits stay (Medellin, 2010) In the second group, i.e., the agroecological markets, campesinos receive support from local associations, such as the Associacin de Campesinos Agroecolgicos de Boquern (ACAB) (Campesino Agroecological Association of the Boquern) and Penca de Sabila that provides technical training about agroecological practices (ACAB, 2012) Methods The research strategy was based on qualitative methods supported by ethnographic community participatory research, which used participant observation, interviews, and focus groups (Israel, Eng, Schultz, & Parker, 2005) I provided new avenues to understand the problem by integrating the ecological model (Bronfenbrenner, 1977) a conceptual tool to provide A distinctive feature of the ecological model is that it does not limit an investigation of this nature to personal influences on behaviors; rather, it provides a means to examine complex interrelationships t hat occur between humans and their environments at different levels ultimately influencing behavioral patterns (Lecompte & Schensul, 1999) It is important to n ote that all data produced by this study are from the perspectives of the campesinos and represent their views of factors across the ecological model. Participants consisted of adult, male/female agricultural campesinos who lived in 10 of the 17 veredas ru ral divisions in San Cristobal. In the study I used snowball sampling and purposive sampling techniques (Bernard, 2006; Creswell, 2009) T wo

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50 cognitive interviews (Drennan, 2003) were conducted with community members of the Travesias vereda to test the instrument as to whether questions were hard to understand by participants. I at tended community action board 1 meetings in some of the veredas in order to present the study and to contact potential participants. I collected the study information through 67 Interviews and 5 focus groups that were audio recorded. Subsequently I transcr ibed the data and analyzed the transcripts by coding and creating themes and categories u sing the N Vivo software. This study obtained approval from the Institutional Review Board (IRB 02) at the University of Florida and from the Medical Ethical Committe e at the University of Antioquia, Colombia. I provided informed consent to all participants. Forms were signed and kept Reflexivity Statement I am a physician from Colombia and I grew up close to the study area. In my medical practice I lived the experience of treating many campesinos who were poisoned from pesticide use and exposure. This poisoning was mainly related to incorrect handling of pesticides and inadequate use of personal protective eq uipment. Others experienced poisoning because of suicide attempts. Due to this professional experience I began to think and question about the factors associated with pesticide use and how campesinos handle pesticides so that they are poisoned. This was m y inspiration for this research. Additionally my father in law is an agronomist and he has taught me 1 Community Action Boards ( Juntas de Accion Comunal ) are legally constituted nonprofit, supportive civic organizations at the local level in charge of social and community social management. They are built by the voluntary participation of residents of a local community who get together to combine efforts and resources to ensure integral and sustainable development, on the basis of the exercise of participatory democracy. National Legal ACT 743, June 5 2002 by which the Article 38 of the 1991 Constitution of Colombia in relation to community action agencies is implemented (published in the Official Gazet te No. 44826 June 7, 2002)

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51 how important it is to cultivate crops without the use of pesticides. He also introduced me to the concept of agroecology. I selected the study site beca use of its location near Medellin ; this made it possible for me to travel back and forth to collect data Additionally, the site is an important source of agricultural products for Medellin. t potential points for public health interventions Participants All participants worked in agriculture. Many of them combined agricultural activities with other partial jobs. The majority of the participants were married (74.68%), adult males (54.43%) who have worked in agriculture for an average of 36 years. Average age was 53 years. The average amount of years in the formal education al system was 6.15 with a standard deviation of 3.82. Demographic information is described in Table 3 1. The total sam ple of campesinos was 79 (sample size n = 79). Out of this number, 43 (54%) were pesticide users, 15 (19%) were in the transition stage in which they still used pesticides but they were slowly introducing agroecological practices to a portion of the land they cultivate, and 21(27%) were campesinos who had completely adopted agroecological practices ( Table 3 2 ) For the analysis I put together the transition group with the agroecological group in the same non users group and named it: agroecological adheren ts Sampling and Participant Recruitment This project used a purposive sampling strategy, to target participants (Creswell, 2009) The first step was to contact community leaders through informati on provided by personnel at the nongovernmental organization Corporacin para la Investigacin y el Ecodessarrollo Regional (CIER) ( Corporation for Research and Regional

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52 Ecodevelopment) based in Medellin. I attended several community action board s meetings in some of the rural divisions (veredas) including Travesias, San Jose de la Montana, El Llano, and La Palma in order to present the project and contact possible participants. This sampling approach can be understood as an applied snowball sampling techni que. Snow ball sampling is a type of nonprobability sampling strategy (Bernard, 2006) In snowball sampling the researcher locates one or more key individuals, often called seeds, and asks them to name others who would be likely candi dates for the specific research issue (Bernard, 2006) Observation I collected observational data using participant observation (Agar, 1996) from May to November 2011 for approximately 5 hours three times a week I took field notes on what I saw, heard, and experienced during the workday. I also recorded observational work, use of protective equipment, and famil y transfer of pesticide residue Board of Directors Meeting I also attended the board of directors meeting of Associacin Campesina Agroecolgica de la region de Boquern Corregimiento San Cristobal (ACAB, Campesino Agroecological A ssociation of the Boquern) (ACAB, 2012) I went to this meeting with the aim of presenting the project to the leaders of the association and obtaining permission to contact campesinos who bel ong to this association ; this constituted the non pe sticide users segment of the study population. Interviews and Focus Groups The interview guide was constituted mainly from the following components: use

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53 and exposure id eas about harmfulness of pesticide use in relation to human health and the environment, decision making about pesticide use and comments about the future of life and the vereda ( Appendix A ) The instrument used for focus groups was the same as utilized for the individual interviews with few minor modifications, considering that most of the questions included in this instrument were relevant in group discussions (Appendix B). The first round of interviews occurred with the initial campesinos (seeds). Follow ing these initial interviews, each contact was asked to provide the names and phone num bers of two or three neighbors. The reading level of the informed consent and interview forms was appropriate for the target audience (fifth grade education). I conducte d all the interviews and focus groups in Spanish. Data Analysis I used conventional thematic content analysis for data analysis (Creswell, 2009; Green & Thorogood, 2004) Conventional thematic content analysis is frequently u sed (Green & Thorogood, 2004) Content analysis is a research method for the subjective interpretation of the content of text data through the systematic organization al process of coding and themes identification (Hsieh & Shannon, 2005) I utilized the following steps to accomplish the content analysis: read all transcripts thoroughl y; derived codes from the transcripts; named codes based on words used by interviewees; sorted codes into broader categories and themes; organized codes, categories and themes according to relationships among them; prepared definitions and examples for eac h code and category; and, repeated the process as necessary until the data were captured within the codes (Hsieh & Shannon, 2005; Richards, 2009; Richards & Morse, 2007)

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54 A product of this process was a code book that included larger categories with discreet codes within them. I trained the research assistant to code data and this way I established inter rater reliability. I met periodically with the research assistant to discuss findin gs and coding along the process. I accomplished d ata highlighting and manipulation through the use of NVivo 8 software package (Richards, 2009) The research assistant and I (both native Spanish speakers) transc ribed all taped interviews and I (bilingual), translated the code book into English. Having a single individual translate all interviews ensured consistency and reliability of the Spanish to English translations. I reviewed the transcript ion s, debriefing summaries, and detailed field notes in their entirety. This approach strengt hened the text analysis process I imported the Word files with the transcribed interviews into NVivo8. After this, (e.g ., gender, age, years of education, occupation). I created free nodes with the initial codes and, later, tree nodes that showed more hierarchical l organizations of findings. I created models out of the tree nodes to visualize themes and broader catego ries. This qualitative analysis process included the steps of descriptive, theme and analytical coding (Richards, 2009) Reliability. This process explores if the study was consistent, reasonably stable over time and across researchers and methods (Miles & Huberman, 1994). I did the following step s to check the reliability of the study: The within the site was explicitly described ; The findings showed meaningful parallelism across data sourc es (informants, context, and times ) ; T he analytic constructs were clearly specified ; Data were collected across the full range of appropriate settings, times, and respondents, as suggested by the research questions ; Because two field

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55 workers were invo lved, they had comparable data collection protocols ; Coding check s were made and they showed adequate agreement ; Data quality checks (e.g., for bias, deceit, and informant knowledgeability) were routinely made ; The accounts of multiple observers accounts c onverged as expected ( in terms of instances, settings, and times ) ; and Different forms of peer review were in place Internal V alidity Validity is the process of checking, questioning, and theorizing if the findings of the study make sense, are credible to the people I studied and to the readers, and to portray an authentic view of at the subject matter (Miles & Huberman, 1994). I did the following step s to check internal validity: I described the context in a rich and meaningful way ; The account rendered was comprehensive because I respected the configuration and temporal arrangement of elements in the local context ; I observed triangulation among complementary methods and data sources producing convergent conclusions ; Results w e re found to be internally coherent and concepts were systematically r elated ; I identified areas of uncertainty ; and Conclusions were considered to be accurate by original informants. External Validity To know if the conclusions of the study have a larger import, are transferabl e to any other context, and how far they can be generalized, I did the following steps (Miles & Huberman, 1994) : I described fully the characteristics of participants, settings, and processes to permit adequate comparison with other samples ; The report exa mined possible threats to generalizability such as sample selection, setting and constructs used I defined the scope and boundaries of reasonable generalization from the study ; The findings include d enough thick tential transferability and appropri ate ness for

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56 their own settings ; Narrative sequences were preserved unobscured ; The report suggest ed settings where the findings could be fruitfully tested further ; I specify that replication efforts could be mounted easi ly in other agricultural campesino communities. Human Subjects I handed out the informed consent and read it in Spanish to the participants Participants signed it before the interview started. I nterviews of the members of the family (e.g. husband and wif e) occurred during the same visit but in separate rooms so as to maintain the confidentiality of the information Only the researcher and interviewee were present. I audio recorded, downloaded, and saved all the interviews and the list that connected the p articipant number with names into my personal computer with double lock access. I describe in more detail the research design and methodology i n A ppendix D. Results Description of Agricultural Practices In the studied population two types of agricultural practices predominate d : pesticide use and non users. Campesinos who belong ed to the pesticide users group utilize d different kinds of synthetic insecticides, fungicides, fertilizers and herbicides. The most common fungicides included Dithane, Manzate, E losal, and Bordeaux ( Table 3 3 ) Widely used herbicides included Gramoxone and Roundup ( Table 3 4 ) In the insecticides category the most frequently used included Lorsban, Malathion and Tamaron ( Table 3 5 ) The most common chemical fertilizer includ ed urea and Grow 500 (Table 3 6). It is important to clarify, as explained in Tables 3 3, 3 4, and 3 5, that most fungicides and herbicides used by participants belong ed to the toxic

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57 category II (medium toxicity) and III (low toxicity); and most insectici des belong ed to toxic category I (high toxicity) and III (low toxicity). Campesinos who belong ed to the agroecological adherents group utilize d other types of substances to combat pests. They mainly use d animal manure, ashes, herbal extracts, and compost (organic matter to fertilize the soil). The most common natural ferti lizer s included compost and manure ( Table 3 6 ) By comparison, most pesticide users mainly cultivated cilantro and chives/onions and sometimes flowers (Table 3 7), whereas non pesticide users cultivated a broader variety of crops including carrots, lettuce, leaks, cucumber, cantaloupe, beans, peas, collard greens, yacn, spinach, radish, parsley, beet, tomatoes, white onion, celery, corn, broccoli, cabbage and even a wide arrange of med icinal plants ( Table 3 7 ) I systematized the following portion of the results in this study around its tree research questions What are the Primary Factors Associated With the Use of Pesticides and How D o T hey D iffer B etween P esticide U ser and Agroecolo gical Adherents ? This section encompasses the depiction of the primary factors associated with practices in San Cristobal. The application of the ecological model resulted in the identification of a taxonomy of themes that were ultimately categorized under the five levels of influence: i ndividual, interpersonal, socio cultural, economic, and political. I discriminated t he main components of each factor for each level as follows: Individual level: knowledge about the need to use pest icides, attitudes ( Figu re 3 4) and beliefs ( Figure 3 5 and Table 3 8) Interpersonal level: family influence and community acceptance ( Figure 3 4 and Table 3 8 ) Economic level: market pressure, economic fear (loss), lack of government support, and crop type (flowers).

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58 Cultural level: pesticide acceptance and reaction when quitting pesticides Political level: Government promot ion of pesticide use, and lack of regulation for protective equipment. I then related all of these contextual levels with their categories in a model ( Fi gure 3 6 ) Overview The principal categories explored in the individual factors included decision making on pesticide use, reasons for pesticide use, knowledge about pesticides, and beliefs and attitude s associated with pesticide use. In the interpersonal factors include d family influence and community pressure, while ( Table 3 8 ) The most relevant categories in the economic factors include d market pressure, economic fear, flower crops, impact of change, economic benefit, and economic support from the gover nment. Important categories for cultural factors comprise d pesticide acceptance (social norm) and the reactions experienced when discontinuing pesticide use. Significant categories in the political factor include d government approval of pesticide use and n o regulations for protective equipment. The ch aracteristics of most of these factors varied greatly between pesticide and non pesticide users. I compared and contrasted them in this section and summarized them to show the dissimilarity of the findings ( T able 3 9) Individual The most important individual categories include d : reasons for pesticide use, knowledge about pesticides, beliefs, and attitudes related to pesticide use. Reasons for pesticide use The reasons for pesticide use or non use varied be tween campesinos in the conventional (users) and agroecologic (non users) groups. The main reasons pesticides users expressed for using pesticides included the prospects of achieving a good harvest (amount of yield), efficient pest control, habituation to use pesticides, pesticides are necessary to grow flowers, obligation to do

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59 it (by land/crop owners) On the other hand, non users indicated an alternative set of reasons to support their decisions for not using pesticides including: better health standa rds (men, women and children), pesticides considered as chemicals that are harmful for everything, pesticides being deleterious for the environment, and being used to /enjoy ing Knowledge about pesticides The s peci fic knowledge base about the use(s) of pesticides was similar between pesticide users and non users. Campesinos explained that pesticides are used mainly to kill the pests that attack their crops (bad insects, although most acknowledge that pesticides also d ecimate beneficial insects), provide demands) facilitate commercialization (easier to sell), have a better crop production (larger yields per unit area ), and protect the pl ants from extreme weather (drought, excessive rain, hail). Campesinos also consider ed that pesticides can kill individuals depending on the level of exposure. In some cases, campesinos expressed that they do not know the purpose of using pesticides, i.e., pesticides are used without having even a basic understanding. It was difficult for participants and their family members to I dentify and recognize some of the health effects of pesticide use due to the fact that many times there are no overt symptoms. I described b eliefs and attitudes related to pesticide use in the next research question. Interpersonal At the interpersonal level categories like family support and community pressure, exerted a strong influence for pesticide use. In terms of family suppo rt, partners (wife or the husband), in general approved decisions made about agricultural work in the users

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60 and non she feels happy because with agroecology productivity is not great bu t there is health and lots of other good things that come with it when I changed to agroecology, I did it mainly because I had support from my family Occasionally, partners in the pesticide users group dis approved of the use of toxic substances by explicitly indicating feeling worried about the agricultural work performed by their family members because they associated it with inherent risks and the recurrent episodes of sickness. For example, they identifi ed specific events of intoxication in their partners through pesticide exposure and reported that they do not want this to happen s he feels worried because I have been poisoned after spraying pesticides. she feels proud of m y work bec ause she knows I am responsible but she worries about my health Economic The most important economic categories include d : market pressure, economic fear, financial impacts of switching to agroecology, economic benefits, a nd lack of government support. Market pressure C ampesinos reported a strong pressure from the market. Their immediate and most compelling need is to sell their products so as to fulfill basic economic survival. It is clear for them that the market sets th e conditions for marketable products, which in Colombia favors pesticide based agriculture. The dominant market them This expression supports the idea we have to spray t he crops right before we take them for sale to las plazas so they can make sure we used pesticides, otherwise las plazas do not buy our crops 8). C ampesinos who practice d agroecology

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61 manifest ed enjoying economic stability and freedom becau se they do not depend on buying pesticides for their crops. Flower growers acknowledge d that pesticide use for flower crops is very intense, meaning flowers need a higher volume and a larger variety of pesticides tha n edible crops Economic fear Campesin os experience d economic fear, i.e., they are afraid of living under economic constraints if they discontinue pesticide use. This fear was linked to perceived risks of yield and quality reduction of their crops, thus making them harder to sell though conven tional markets, as well as crop failure due to plagues or extreme weather conditions. This economic fear ha s ramifications related to governmental policies for the agribusiness sector in Colombia, i.e., lack of technical and economic support for small scal If we lose our crop due to pests or weather we do not have any economic support from local or national governments to survive (Participant No 32). Non users express ed a sense of economic and food accessibility independence (autonomy) as t hey can tap into smaller yet equally profitable alternative markets ( Colyflor ), and can rely on food supplies from their plots due to a greater variety of food stuffs produced Over the long term, and in clear contrast relative to pesticide users, campesin os in the agroecology group perceive amelioration of soil conditions (fertility, amount of organic matter, biologic diversity, etc.), that allows them to establish we have food when we need it and we do not waste money on pesticides Economic impacts of change Campesinos who shifted to agroecological practices indicated they experienced different impacts. Campesinos mentioned that when they initially shifted to agroecologi cal practices, the first year of production was

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62 very poor because the soil was contaminated ," but after this period they began to see good production again. Even though crops take a longer time for harvesting, there is a positive mid to long term economi c impact due to shrinking reliance on buying the raw material and supplies (agrochemicals) required for conventional, modern agriculture and the effects on agroecological practices on soil quality. Economic benefits C ampesinos in the user group judge d t hat utilization of pesticides brings economic benefits because they produce more voluminous crops and pesticide users, conversely, d id not notice any economic benefit fr om this factor and express ed it is actually more expensive to buy/apply pesticides. Through local organization and assistance programs form NGOs (ACAB, Colyflor, and Penca de Sabila ) the option of alternative organic markets is now considered as equally vi able from an economic standpoint. Government support Government support is sca rce in this community. Campesinos express ed that, before any transition to stop pesticide use is set in motion, there must be government based economic support policies in pla ce, partly because at the beginning of the change there is a great risk of significant economic loss and financial support is need ed to with stand the transition to agroecology: we need economic support to survive this transition Participant No 64) For both groups it was c l ear that in its actual situation the government does not provide any type of regular salary, paid vacation, retirement plan or other economic benefits for the independent workforce in agriculture, and that prospects for change are dim

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63 Cultural Pesticides were widely accepted in this community. At large, they were even campesino transition s to agroecological practices disapproving reactions exist they think we are w eird was an evident and prevalent social norm in agricultural communities in Colombia with regards to pesticides use. It has already been noted that campesinos in the user group convey ed that production is faster, crop yields ar e significantly larger and fruits vegetables possess better qualities when cultivated with the aid of pesticides. In contrast, non users expressed that the crops look bigger in size and appearance with pesticides but that the flavor is better when they ar e cultivated agroecologically. Additionally, pesticide use is a habit in these campesino communities. Community beliefs about pesticide effectiveness and the desire to adhere to the culture of high speed production : life and consumption take place at high speeds The harvest has to be ready and good for sale as quickly as possible (Participant No. 42). T he opposing view of the non user group was Thing is: sell s lower and less amounts, but (Participant N o. 13). Most pesticide users in the community react negatively when someone in the vereda quits pesticide use or even when someone starts to change agricultural production routines to reduce pesticide use through implementat ion of agroecological practices : to work with rotten waters and manure (Participant Nos. 35, 45, 60, respectively).Non pestic People do

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64 not want to believe we have been able to work agroecologically (Participant No 28) All these cultural components configure a specific environment i n which campesinos live Political At the policy level, campesinos were not compelled by regulations in relation to pesticide use and exposure They never receive d visits from governmental institutions with the aim of supervising their work or provid ing advice as to pesticide use guidelines In regards to protective equipment the regulatory laws exist but they are not implemented. T he government d id not facilitate the training of campesinos about proper equipment, adequate handling and a pplication techniques, or osage The majority of campesinos in the users group employ ed was scant and often utilized in inappropriate ways. In addition, all sorts of improvis ed was used by campesinos during pesticide handling, preparation, and spraying The most commonly used equipment includ ed plastic boots (98.5%), cotton mask (9 %), and plastic goggles ( 9%) ( Table 3 1 0 ) During the participant observations, campe sinos never wore appropriate personal protection equipment (PPE) during pesticides preparation or application. Campesinos in the studied communities reported that they have never received visits from regulatory agencies for training o r to observe if they a re adopting adequate protective measures for themselves, their families/community and the environment. Several campesinos involved in flower production have been given masks with mouth nose filters by Asocoflores (a flower grower association) but they do n hot and uncomfortable (Participant No 40). Most pesticide users in this research ha d not received any training at all. In the better cases, and when literacy permits, they read the label on the

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65 container and follow ed directi ons as they interpret them : I have not received any training but in the pesticide containers says: use mask, gloves and shower after use, sometimes I shower right after spraying and other times at night because I am very busy How do P esticide U sers and Agroecological Adherents C ampesinos D iffer in their A ttitudes and B eliefs S urrounding P esticide U se? Different attitudes and beliefs exist ed related to pesticide use and they portray ed some differences between the pesticide users an d non users groups Attitudes related to pesticide use Fear was an important affect attitude in relation to the idea of stopping pesticide use. This fear was mainly related to the evaluative comments of the community if they discontinue use. Non pesticide kept we think pesticides are harmful for our health a nd the environment, I would never use pesticides again (Participant No 62). With regards to the possibility of stop ping pesticide use, individuals in the modern conventional agriculture group held a negative evaluative attitude; they would stop if they co uld have economic warranties, e.g., clear state or private initiatives to help them financially and logistically in the case they lose their crops. A minority of pesticide users displayed a positive attitude toward the possibility of quitting pesticide use if they receive d good technical advice Non pesticide users expressed that after having learned to grow their crops without pesticides, they would not start pesticide use again it would be like stepping back and losing what I have learned No 66)

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66 Beliefs associated with pesticide use Beliefs categories on pesticide use and exposure included: situations that may arise if pesticide use is discontinued in the crops, usefulness of pesticides for your crops, and harm related to pesticide use for human health and the environment ( Table 3 1 1 ) Beliefs about what would happen if pesticide s are discontinued Many campesinos believe d that, on quitting pesticide use crop amount and quality would drop significantly. A prevalent idea among pesticide us ers implie d that pesticides support healthier crops that produce larger amounts (yield per unit area) with better quality (physical appearance). This facilitate d non pesticide users state d t and nutritional va lue ) is inferior compared to crops produced agroecologically. Beliefs associated with adverse health effects of pesticides Participants expressed c oncerns relative to their partners as the latter (mostly wives) are mainly affected by pesticides when they breathe contaminated air with these substances after spraying. They can also get affected by washing (by hand) the clothes used by their partners du ring pesticide spraying/applications and by eating food that contains pesticides. Male agricultural workers believe d women are more susceptible suffering abortions and allergies on the skin (Participant No 45) Several campesinos indicated they deem there is no harm for themselves : If I cover myself with a cotton mask nothing happens Participant No 62); If I wash the vegetables with hot water and bleach before we consume them p esticides will not

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67 affect us (Participant No 52) A consistently negative perception of pesticides effects on existed because adult agriculture workers (male and female alike) judge d that children weaker bod ies than adult s Partic ipant No 34) Campesinos believe d pesticides can produce negative effects even starting with conception such as cleft palate or other malformations : pesticides can affect the fetus in general (Participant No 41 ) p esticides can produce other problems su ch as intoxications, respiratory problems, allergies skin irritations and respiratory diseases on children (Participant No 30) During this study I observed that the population of children was not directly involved in the spraying and preparation of pes ticides. However, they were indirectly exposed by living near the fields were pesticides were used and stored. Beliefs linked to adverse effects of pesticides on the environment These findings integrated beliefs related to different environmental compone nts including water, soil, non human animals, plants and air. Most campesinos believe d pesticides contaminate water in general but several have the misconception that pesticides pollute water only if they are applied or disposed directly into the springs. Another idea was that when pesticide containers are thrown into main water sources or spraying equipment is washed in the sources, they contaminate the water and change the Participants considered that w ater contamination was deleterious only when people and animals drink directly from main streams containing pesticides Regarding the negative impact of pesticides on soil, the main beliefs consisted of soil killing beneficial soil organisms (e.g., earth worms), and make soil los e fertil ity

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68 overtime. F ew campesinos, particularly those in the users group, expressed the belief they actually help the soil (Parti cipant No 23) Beliefs associated with the impact of pesticides on animals incorporate d many ideas that pesticides affect and kill microorganisms, beneficial insects, birds, and domestic animals (e.g., cows that eat grass contaminated with pesticides). M ost participants believe d pesticides contaminate air, especially when crops are sprayed and the wind scatters the chemical compounds around, thus increasing the extent of geographic areas that can be affected. Ideas about simple antidotes ( contras ) for p reventing and or treating pesticide intoxication prevail ed in the community. For example, there existed an entrenched harmful health effects, especially intoxications : I receive protection and prevent intoxication if I drink milk (Participant No 41) When I am spraying pesticides and feel dizzy, I drink cold milk and feel better right away! (Participant No 39). B enefits of pesticides In relation to perceived benefi ts of pesticides, a common idea among users was that pesticides promote faster crop growth (more harvest seasons per year), better yields, larger sizes for a given crop In floriculture pesticides an absolute need, plants look prettier and (Participant No 50) Additionally, many individuals th ought pesticides contribute to making agricultural work and requires less frequent spraying than agr oecological products. N on users recognize d that agroecological practices may be more labor intensive but they see no benefits associated with pesticide use.

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69 Pesticide Use and exposure ? T his question was specifically related to the decision making process of pesticide use, and utilization of protective equipment. Decision making about pesticide use The decision making process of pesticide use was mainly influenced by the following compon ents: a) Individual: low knowledge about harm of pesticides, the beliefs that pesticides are necessary for the crops, negative attitudes to stop ping pesticide use. b) Interpersonal: Family influence toward pesticide use, and community pressure. c) Economic fear, lack of government support and growing flowers as an alternative means of generating better income. d) Cultural: pesticide acceptance (social norm), and negative community rea ction when halting pesticides use. e) Political: government promotes pesticide use, and there are no regulations for protective equipment. I summarized a ll these factors with the most relevant categories in a model about the pesticide use decision making p rocess (Figure 3 7 ). When these categories exist ed in the life of campesinos, they were more likely to use pesticides. Some campesinos expressed that You only need to buy it, know how to prepare the mixtures, and sp it is easy to use (Participant No 6). A barrier to stop pesticide use was relate d to pesticides as being deeply accepted and entrenched in for mal agricultural practice, in their culture and in the community. An important source of support that many campesinos found in transitioning to

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70 agroecological practices c ame from the NGO Penca de Sabila which gave them training about agroecological practi ce s and constant technical support Protective equipment Numerous beliefs exist related to the use of PPE among campesinos. PPE use was deficient in the study population as stated previously. In justifying the lack PPE use many pesticide users believe t expressed that they do not need to use protection, and that PPE make S ome campesinos indicated that they recognize pesticides as dangerous substances and they should use protective equip ment, but they are simply careless about i t and are not used to wearing it Other less common but important reason s for the lack of PPE use revolves around relations between the agricultural workers and plot parcel owners as the latter consistently try to cut costs and never provide PPE or training. This becomes more an issue of dependence and power. Similar economic constraints negatively impact the adoption of adequate protection schemes against pesticide s as a complete set of PPE can be expensive, which in an already subdued family economy makes it virtually impossible to purchase and maintain adequate gear. The situation is aggravated du e to the lack of governmental subsidies and/or programs that would provide PPE and training. Further, there are no pol icies in Colombia that regulate or enforce the use of PPE. All of these factors play an important role i n the use of protective equipment and they are described in a model in Figure 3 8

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71 Discussion and Interpretations What Are The Primary Factors Associat ed With The Use of Pesticides and If They Differ Between Pesticide User and Agroecological Adherents ? Many pesticide users admit that they do not understand and are not well informed about the harmfulness of pesticides for their health and the environment Lack of thorough understanding brings up an important issue because it shows how pesticide use is a human behavior related to factors like habit, social norms, or cultural acceptance without a clear justification or knowledge. This finding in turn im pl ies the need to organize public health interventions targeting pesticide users to improve a basic knowledge related to the detrimental effects of pesticides on human health and the environment so campesinos can use that knowledge in reaching informed decis ions on pesticide use and exposure and work with the aim of obtaining behavior change Additionally it is important to increase the level of awareness about the adverse effects of pesticide use because, as mentioned earlier, they might know pesticides are Many workers avoid attempting to stop pesticide use due to the economic fear they experience with regards to a decrease in income linked to crop failure and/or reduced possibilities to market t heir products when shifting from agrochemical base agriculture schemes to agroecology. Clear, well established sources of financial support to their work (e.g., governmental subsidies) could guarant ee facilitating the adoption of agroec ological practices. As a general rule, campesinos now in the agroecological adherents group initially faced significant economic losses for periods of 1 to 2 years or more. After overcoming the 1 2 year threshold, they began to see the positive effects of agroecological practices on their crops and on their economic

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72 status; not to mention the sense of well being experienced by all as they grow in confidence concerning their financial, technological and food sovereignty. Considering that the market exerts a profound influence on deciding whether to use pesticides, more support to campesinos in the realm of fa ir trade and agroecological markets is urgently needed. The size and reach of existing programs is still small in comparison to the amount of individuals participating in agricultural production in Antioquia. This economic support could be accomplished through new governmental policies that foster agroecological practices so as to assure logistic and financial support to campesinos just as it is implemen ted in countries such as the United States, France and England (Bills & Gross, 2005) Many pesticide related ideas were culturally accepted. Pesticides were considered as something normal, and a desirable helpful tool in agriculture Culturally sensitive educational interventions about the harms of pesticides to human health and the environment would con tribute to change this social norm. However, the low educational attainment of the campesino population adds additional challenges to the task of increasing the occupational health and safety of this working population. mented policies or serious regulations for the use of pesticides or protective equipment. As a norm, pesticide users in this study exhibit deficient utilization of PPE, if they use any at all, thereby increasing exposure and associated risks of intoxicatio ns and other harmful health effects. Therefore, work at the policy level is important to improve regulations, supervision education and training in regards to safe use practices.

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73 Additional research efforts are also required to provide further information about all these multilevel factors in other geographic locations of Colombia where intensive pesticide use is also prevalent. V ariable cultural trends exist in Colombia among agricultural communities, thus more community participatory ethnographic studies in different regions could provide a better understanding of the cultural factors associated with pesticide use and generate active community involvement. These findings could help researchers to design future public health interventions that would be cul turally appropriate. Future research should be geared towards an exploration of alternatives that can culturally open the option of agroecology. The recent incorporation of a doctoral program in Agroecology at Universidad de Antioquia Medellin in conjunc tion with the work being advanced by NGOs such as ACAB, Colyflor, CIER, and Penca de Sabila (including organic markets administered or advised by them) are expected to have a p ositive effect in the transition of agricultural campesino communities to agroec ological practices. How Do P esticide U sers and Agroecological A dherents C ampesinos D iffer in T heir attitudes and B eliefs S urrounding P esticide U se? Public health interventions would be beneficial in the pesticide user population in order to generate more a wareness about the implications of pesticide use. These activities could promote the development of a better supported understanding of the negative impacts on health linked to the use of pesticides as well as the possibilities inherent to agroecological p ractices with the aim of reducing or ideally eliminating pesticide use. to farmer

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74 community use their agricultural plots as an experimental pedagogic milieu within the community to teach each other and share their experiences in the realm of a groecology T his approach has demonstrated excellent and sustainable results (Sanchez Morales, Ocampo Fletes, Snch ez Hernndez, & Martnez Saldaa, 2008). The main attitude to promoting p esticide use and abuse among pesticide users was fear. Forms and causes for apprehension should be studied in more detail in the near future with the aim of helping campesinos find al ternatives to cope with it, on the basis of a more integral understating of their problematic situation, and hence facilitate pesticide reduction. Non pesticide users who already overcame this fear could serve as examples guiding their fellow campesinos th rough the decision making process. The farmer to farmer education methodology could also be particularly useful to this objective. Pesticide Use and exposure ? Future public health interve ntions should try to increase knowledge about harm of pesticides, and bring factual information to modify the beliefs that pesticides are necessary for the crops. These interventions should also try to transform the negative attitudes to stop pesticide use so campesinos can be more confident about reducing use and gradually transition to agroecological practices. All of the campesinos who have shifted to agroecological practices strongly emphasized that family support was crucial in making the decision. B ased on this finding, prospect ive public health interventions focused on strengthening family support should contribute to facilitat ing the decision making process of reducing/stopping pesticide use. Upcoming studies should explore in more detail family dy namics and social networks and their role in the decision making process of pesticide use or

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75 ag roecology. A stronger support o f Penca de Sabila, ACAB, and similar organizations would certainly contribute to increasing the positive impact on pesticide use among target agricultural communities in San Cristobal. Support from the Colombia n government and other stakeholders in the form of economic subsidies and practical training/assistance, as well as encouragement of agroecological markets could also facilit ate the decision making process to stop pesticide use. Future interventions should also include the community so as to transform social norms about cultural acceptance of pesticides in the community. At the political level policy makers should work, with the advice of academia, in the design of coherent laws and regulations for pesticide use and be more vigilant about their enforcement. The frequency of having received pesticide training s in this study population was low er than those reported by other s tudies carried in the United States (Arcury et al., 2002; Elmore & Arcury, 2001; Quandt et al., 2001; Quandt et al., 1998). Therefore there is a clear need to improve safety conditions and training in this campesino population in Colombia to reduce occupa tional hazards. Public health interventions targeted to this population should incorporate activities aimed to increase awareness about the importance of the use of PPE equipment followed by a subsequent goal of producing a behavioral change that can impr ove the use of these protections. Strengths and Limitations of t he Study A major strength of this study, that differentiates it from similar works in the literature, stems from the comparisons drawn between pesticide users and non users populations. In add ition, a wealth of data was obtained directly from the population of interest, and participants had an opportunity to describe their ideas in their own words.

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76 Focus groups participants had the ability to contribute to the comments of others, which served t o provide an in depth understanding of the ideas and concerns. It must be noted, however, that focus groups discussions relied heavily on the skills of the moderator Individual interviews were guided by a pre established interview form w ith open ended que stions There is a possibility that interviewers and focus group moderators may have inadvertently influenced responses. Due to the sample size and the purposive sampling strategy utilized in this study, results cannot be generalized beyond the studied par ticipants. Although these limitations are recognized, thoughtful planning of the individual interviews and focus groups questions and extensive training of the focus group moderator were designed to offset them. Conclusion Pesticide users experience more f ear to stop pesticide use and believed pesticides produce larger yields and bigger crops. Pesticide users do not display a positive attitude toward proper personal protection (PPE), regardless of th e risks involved in the trade Training on pesticide use i s deficient throughout both populations studied showing a clear need to improve safety conditions and training to reduce occupational hazards. Future studies should explore in more detail these attitudes and belie f s. Public health interventions to be desig ned must address campesinos fear to stop using pesticides and educate pesticide users to change these belie fs and to understand that agricultural practices can match pesticide based agriculture as far as crop amounts and quality while providing a signific antly better environment to keeping high heath status (e.g., technological, food, economic and health sovereignty). Campesinos who possess low knowledge about adverse effects of pesticides, who believed pesticides are necessary for their crops, who had n egative attitudes about

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77 discontinu ing pesticide use, who had strong family influence s to use pesticides, and who experienced economic fear to stop pesticide use were more likely to use pesticides. Similarly, campesinos who partake in the floriculture marke t (marked by a strong social acceptance of pesticides), who experienced negative community reactions when trying to stop pesticide use, who had received government subsidies for pesticide use, and who had not received any training about protective equipmen t, were more likely to use pesticides for their crops, and showed reduced proclivity to abandon pesticide use. Future research and intervention s targeting all these aspects could reduce pesticide use in this population. Forthcoming public health interven tions should target both pesticide users and non users to increase awareness about the health and environmental benefits of agroecology. Pesticide cultural acceptance constitutes a complex environment in which campesinos have to live, putting an additional obstacle for agroecology in the region. There is a clear need to improve economic conditions and regulatory policies in order to help reduce pesticide use and exposure in this population.

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78 Table 3 1. Demographic information of participants Demographic s (%) Gender: Male 54.43 Female 45.57 Marital status: Cohabitates 7.59 Divorced 5.06 Married 74.68 Single 8.86 Widow 3.80 Occupation: Only agriculture 41.77 Agriculture and chicken production 1.27 Agri culture and employed in factory 1.27 Agriculture and flower grower 6.33 Agriculture and housework 41.77 Agriculture and jornalero 1.27 Agriculture and m e rchand 2.54 Agriculture and mowing 1.27 Agriculture housework and medici nal plants garden 1.27 Agriculture, painter and house work 1.27 Residence (vereda): Carmelo 8.86 Cuchilla 3.8 El Patio 2.53 La Palma 8.86 El Llano 12.66 Las Playas 8.86 San Jos de la Montana 17.72 Travesi as 29.11 Uvito 3.8 Yolombo 3.8 Age (median): 53.00 years Education (mean) 6.15 years Education (std) 3.32 years

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79 Table 3 2. Group of participants Pesticide use/no use Frequency % Only pesticide users 43 54 Transition (combine pesticide use with agroecological practices) 15 19 Only agroecology 21 27 Total 79 100.00 Table 3 3. List of Fungicides used by total sample of campesinos Comercial name Active ingredient Toxic category Chemical group % Camp esinos who use it Dithane Mancozeb III Ditiocarbamate 74.2 Manzate Mancozeb III Ditiocarbamate 67.7 Elosal Elemental sulfur III Inorganic 64.5 Antracol Propineb III Carbamate 12.9 Daconil clorotalonil II Ftalonitrile 12.9 Polycal Calcium Polis ulfur III Calcium polysulfide 6.5 Oxycloride Cu Oxicloruro de Cu III Inorganic 6.5 height 100 Cyproconazol III Triazol 3.2 Curathane Mancozeb, cymoxanil III Ditiocarbamate 3.2 Terrazole Cooper Hydroxide III Inorganic (Cooper) 3.2 Mancozeb M ancozeb III Ditiocarbamate 3.2 Metax Mancozeb; metalaxil III Ditiocarbamate ; acilalanine 3.2 Silvacur Teboconazole; Triadimenol II Triazol 3.2 Forum Dimetomorph II Cinnamic acid 3.2 Amistar Azoxystrobin IV Metoxicrilate 3.2 Bordeaux mixture C ooper sulphate Inorganic 50.0 Iodine Iodine Complex III Inorganic 38.5 Lime sulfur Sulfur, quicklime Inorganic 9.7 Note: 19% of total sample of campesinos are in the transition stage. Therefore, they do follow agroecological practices but they stil l use some pesticides for their crops, especially for flowers. This is why some percentages go beyond 50%.

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80 Table 3 4. List of Herbicides used by total sample of campesinos Comercial name Active ingredient Toxic category % Campesinos that use it Gra moxone Paraquat I 22.5 Round up Glyphosate IV 3 5 5 Rocket Glyphosate IV 12.9 Panzer Glyphosate IV 9.7 Afalon Linuron III 9.7 Prowl 400 Pendimetalin III 3.2 Faena Glyphosate III 3.2 Table 3 5. List of insecticides used by total sample of campesinos Comercial name Active ingredient Toxic category Chemical group % Campesinos who use it Lorsban Clorpirifos III Organophosphate 54.8 Malathion Malathion III Organophosphate 45.2 Tamaron Metamidofos I Organophosphate 29.0 Methavin Met omyl I Carbamate 19.4 Roxion Dimetoato II Organophosphate 16.1 Furadan Carbofuran I Carbamate 16.1 Nadir Metamidofos I Organophosphate 16.1 Vertimec Abamectin II Agent derived from microbian 12.9 Parathion Metilparathion I Organophosphate 9.7 Ev isect Thiocyclam hidrogenoxalat e III Nereistoxin 9.7 Lannate Metomyl I Carbamate 6.5 Curacron Profenofos II Organophosphate 6.5 Apache Cipermetrin II Piretroid 6.5 Rafaga Clorpirifos III Organophosphate 3.2 Temik Aldicarb I Carbamate 3.2 Monito r Metamidofos I Organophosphate 3.2 Regent Fipronil III Fenil pirazol 3.2 Cipermetrin a Cipermetrin II Piretroid 3.2 Orthene Acefat e III Organophosphate 3.2 Karate Lamdacialotrin III Piretroid 3.2

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81 Table 3 6. List of chemical Fertilizers used by total sample of campesinos Comercial name % campesinos who use it Chemical Fertilizers: Urea 35.1 G row 500 19.4 10 30 10 9.7 15 15 15 6.5 Fertilika 6.5 T otal 6.5 Terrasol 6.5 P roduction 3.2 Nitron 3.2 All in 1 3.2 10 20 20 3. 2 14 14 14 3.2 Natural Fertilizers: Compost 9 6.2 Manure 42.3 Worm compost 26.9 Ashes 3.8 Sugar paste wood chips 3.8 Nitrafos 3.8

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82 Table 3 7. List of crops comparing pesticide users with non pesticide users Crops Pesticide users (%) Non pesticide users (%) Total (%) Cilantro 55.3 44.7 66.7 Chives 45.7 54.3 61.4 Flowers 50 50 42.1 Medicinal plants 15 85 35.1 Carrots 14.3 85.7 24.6 Lettuce 23.1 76.9 22.8 Leaks 0 100 19.30 cucumber 10 90 17.50 Beans 44.4 55.5 15.8 Peas 11.1 88.8 15.8 Collard greens 22.2 77.7 15.8 Yacn 0 100 14.0 Spinach 14.3 85.7 12.3 Fruits 28.6 71.4 12.3 Radish 66.6 33.3 10.5 Parsley 33.3 66.6 10.5 Beet 0 100 10.5 Tomatoes 20 80 8.8 White onion 0 100 7.0 Celery 0 100 7.0 Corn 25 75 7.0 Broccoli 0 1 00 5.3 Cabbage 0 100 3.5 Chard 0 100 3.5

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83 Table 3 8 List of components of the interpersonal and individual factors Microfactors Description of components Interpersonal factors : Family support. Some families support pesticides Community ap proval or disapproval Either community approves or disapproves pesticide use Individual factors : Decision making about pesticide use It is easy or difficult to use/stop pesticides Reasons for pesticide use What kind of reasons campesinos express a bout pesticide use Knowledge about pesticides What the term pesticide means for them. What pesticides are used for The need to use pesticides Beliefs associated with pesticide use showed in Table 3 11 What are the beliefs campesinos express about pest icide use. Attitudes related to pesticide use What attitudes campesinos have in relation to pesticide use

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84 Table 3 9 List of main contextual factors comparing pesticide users with non pesticide users. This is discussed in detail in the results of the first research question. Pesticide Users Non Pesticide Users Cultural: Culturally accepted that crop is bigger and better quality using pesticides (social norm). Pesticide use is a habit. Community believes on pesticide effectiveness. Community wants a high speed production. Cultural: Have been able to overcome the social norm of pesticide use. The agroecological adherents community does not believe on pesticide effectiveness anymore Economic ( Market): La Plaza and other intermedi aries pay low prices. Economic (Market): Colyflor fare trade market pay higher prices. Economic fear: Campesinos feel fear if they change to agroecology. Economic fear: They already experienced the fear and got over it. Economic loss : Ec onomic loss for buying pesticides, they are very expensive. T end to grow monocultures and depend more on money for buying their food. More dependent of cash to buy food Economic gain: Economic gain for not having to buy pesticides Grow more variet y of crops and eat most of them, they do not have to buy them. They feel more independent economically. Economic impact of change: They think they would lose everything They do not see economic future without pesticide use. Prefer to continue us ing pesticides because crops grow faster. Crops not well paid in the plaza No improvement in health, wellbeing and in the environment. Economic impact of change: No t much money without pesticide, but improvement in quality of life. They see a good economic future. Crop takes longer to be ready to sell but it is worth it. Positive impact because there is less dependence on buying the raw material and supplies Crops well paid at Colyflor. Improvement in health, wellbeing and in the environment Economic benefits: Sell more amounts of crops using pesticides Economic benefits: They do not see any benefit.

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85 Table 3 1 0 List of protective equipment utilized by campesinos Type of protective equipment Number of users % of users Plastic gogg les 6 9 0 Plastic piece on the back 1 1.5 Plastic gloves 0 0 Proper mask with filter 0 0 Plastic pants and blouse 0 0 Cotton mask 6 9 .0 Handkerchief (used as mouth and nose cover) 3 4.5 Plastic boots 66 98.5 Complete appropri ate equipment 0 0 Total participants 67 100 Note: the cumulative percent is more than 100 because some of participants used more than one type of protection. Table 3 11 List of Beliefs related to pesticide use Beliefs Description of beliefs Happen n o pest: What would happen if you do not use pesticides in your crops Useful of pesticides Usefulness of pesticides in campesinos crops. Use of protective equipment What campesinos believe about the use of protective equipment. Harm of pesticide If c ampesinos believe there is any harm related to pesticide use and which ones. Human health: harm of pesticides for human health. Enviroment: harm of pesticides for the environment Drinking milk The belief that drinking milk after fumigating protects them against pesticide harmful health effects, specially intoxications. Benefits pesticides Perceived benefits of pesticide use. Benefits agroecology Perceived benefits of agroecological practices.

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86 Figure 3 1. Map of Colombia Antioquia department an d municipality of Medellin (red dot).

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87 Figure 3 2. Shaded relief map of Medellin municipality ( see different urban jurisdictions to the metropolitan is one of the five Co rregimientos (rural divisions) displayed in tones of green Many of the topographic depressions harbor natural, permanent water bodies (e.g., creeks, etc.) that are tributaries to the Medellin River, major fluvial artery that runs along Medellin City and d ebouches in the Magdalena river. of Medellin municipality (urban area in pastel colors) with the different Corregimientos (rural sub regions in green colors).

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88 Figure 3 3 San Cristbal with 17 rural sub divisions (veredas). General cartography and current land use. The region has high agricultural (yellow, and brown) and livestock activities (managed traditional livestock and unmanaged pasture activities in shades of green).

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89 Figure 3 4 Conceptual m odel of Interpersonal and individual factors related to pesticide use. The most relevant categories under interpersonal factors are family influence and community pressure to use pesticides. The most relevant categories under interpersonal factors are: decision making, reasons for pesticide use, know ledge about pesticides, beliefs and attitudes. The main attitudes include fear, negative attitude in relation use of protective equipment, negative attitude about stop pesticide use and non users do not see their lives using pesticide again.

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90 Figure 3 5 Conceptual m odel of beliefs related to pesticide use. It shows all the main categories: what happens if pesticide use stops, usefulness of pesticides, use of protective equipment, harm associated to pesticides, drinking milk protect them from getting p oisoned benefits of pesticide use, and benefits of agroecology.

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91 Figure 3 6 Conceptual model displaying all the contextual factors and the specific components for each factor described in the text The main factor include cultural (pesticide accepta nce and community reaction when someone quits pesticide use), political (lack of government support and no laws for regulate use of protec tive equipment), and economic ( growing flowers, market pressure, economic fear, economic loss when stop pesticides, im pact of change to agroecology, economic benefits of pesticide use, and little government support).

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92 Figure 3 7 Conceptual model including most influential categories of each factor on os that experienced all these categories were more likely to use pesticides (thick arrow) and less likely to work agroecologically (thin arrow)

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93 Figure 3 8 Conceptual m odel depicting the factors that influence the use of protective equipment. Inadeq uate use of protective equipment was associated to: powerless feelings with bosses, economic difficulties because of the cost of the equipment, belief that equipment is not necessary, deficient training about safety practices, spraying without equipment is a habit, and the fact that no policies exist in Colombia that regulate the use of protective equipment.

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94 CHAPTER 4 A QUANTITATIVE ANALY SIS OF COLOMBIAN CAM PESTICIDES: SURVEY D EVELOPMENT Summary The campesino agricultural communities in Colombia are vulnerable in many domains (econom ic, health ) and they remain a crucial target population for medical and public health studies. Campesinos are at a high risk of occupational hazards, such as those derived from pesticide use and exposure This study focuse d on individual factors that influence pesticide use and exposure. I collected 79 questionnaires with adult (male and female) rural agricultural campesinos in San Cristobal, Antioquia, Colombia. I s harm for human health and the environment, as well as beliefs, attitudes, perceived control and perceived confidence related to pesticide use. The findings differ ed between two campesino groups sampled: pesticide users and agroecological adherents Pes ticide users experienced lower perception s of pesticide harm for human health and the environment, lower perceived control about stopping pesticide use ( an increase in one unit in control decreases the logit of using pesticides by 74 % ) and lower confidenc e about stopping pesticide use than non pesticide users (an increase in one unit in confidence decreases the logit of using pesticides by 64%) I discuss individual influences on occupational safety and health and recommend that future public health and ed ucational interventions should improve safety training and confidence so campesinos can gain control of the process for implementing behavioral change related to pesticide use reduction. Introductory Remarks Pesticides have many times constituted an immed iate solution to pest problems in crops (Gomiero et al., 2008) However, pesticides have produced adverse effects on

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95 humans and the environment alike, that make their use unsustai nable (Harrison, 2011; Pimentel et al., 2009; Shiva, 2009) Pesticides are also responsible for the emergence of increasingly resistant pests/pathogens and the destruction of natural pest enemies (Gomiero et al., 2008) Biodiversity has been strongly altered by synthetic pesticides. Pesticide residues in different ecosystems, soil, water, air, animals and plants are other deleterious results of conventional agricultural practice (Vergara, 2000) Campesinos in many countries where conventional agrochemical based agriculture constitutes the predominant form of production in the agricultural sector, directly suffer from all of the severe threats to human health and well being posed by exposure to pesticides (Jimnez & Muoz, 1993; Nivia, 2000) The majority of pesticides that are banned in first world countries are widely employed in Latin America ( Altieri, 2002) In some nations, it is legal to import banned pesticides from developed countries produced by transnational companies (Castro, 2003) In this section I describe and analyze the individual factors of risk perceptions, knowledge, beliefs, and attitudes, associated with p esticide use by campesinos employing a quantitative approach. Many health alterations have been associated with pesticide use (Freeman, 2007; Ott et al., 2007; Pimentel, 2007; Rothlein et al., 2006) A variety of human systems can be affected, including the neurological, immunological, respiratory and repr oductive ( Guillett e et al., 1998; Nivia, 2000; Quandt et al., 2001; Restrepo, Muoz, Day, Parra, Hernandez et al., 1990) Several potential m eans of exposure exist. However, transdermal exposure seems to be the most common and significant exposure route for agricultural workers (Ministeriod eSalud, 2010; Reigart & Roberts, 1999; Vergara, 2000) Body regions such as the head and the navel/mid thigh segments can absorb pesticides

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96 extremely fast. The greatest risk and highest toxicity are linked to skin and mucosa contact with pesticides during preparation, mixing and application. At the time of mixing, pesticide concentrations are elevated and the li kelihood of injury is increased (MSU, 2012) Effects of exposure range from acute intoxications to chronic conditions including developmental and neurologic alterations (Ott et al., 2007 ; Nivia, 2000; Reiga rt & Roberts, 1999; Rothlein et al., 2006) Exposure not only affects the farmworker directly involved in the manipulation of toxic substances but also other household members such as children and pregnant women (Freeman, 2007; Guillette et al., 1998; Sanmiguel Valderrama, 20 07) Even though a growing concern about pesticide exposure of farmworkers and their families exists, relatively few studies have tried to test directly th e association of behavioral factors with pesticide exposure in agricultural population ( Qu andt et al., 2006) Several r esearch studies have explored beliefs, attitudes, knowledge, risk perceptions, perceived confidence and perceived control surrounding pesticide use (Arcury et al., 2002; Elmore & Arcury, 20 01; Flocks, Monaghan, Albrecht, & Bahena, 2007; McCauley, Sticker, Bry an, Lasarev, & Scherer, 2002; Quandt, Arcury, Austin, & Saavedra, 1998) Some of these studies have explored the perceptions of control, perceptions of risk, and pesticide knowledge amo ng Latino farmworkers in the U nited States, finding limited knowledge and low risk perceptions (they do not feel at risk they mix, prepare or spray with pesticides). These findings suggest that more research is needed and that different education al interve ntions are important (Arcury et al., 2002; Grieshop, Stiles, & Villanueva, 1996; McCauley e t al., 2002; Salazar et al., 2004)

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97 Perceptions about Use of Personal Protective Equipment In a study with migrant farmworkers in the US exploring workplace characteristics only 18% reported wearing any type of protective clothing or equipment. The vas t majority report ed wearing working clothes into their homes (McCauley et al., 2001) Th is study also demonstrated that workers have multiple misconceptions about the characteris tics and appropriate use of PPE. Participants in said study believed that improvised devices, such as bandanas, provide enough protection against pesticide exposure (McCauley et a l., 2001) A study performed with adolescent Latino farmworkers exploring knowledge and risk perception about pesticides, found that use of protective equipment was deficient. A large proportion of these farmworkers (42.2%) reported the belief that they were never exposed to pesticides in their work, and (40.2%) and many reported that there were no ways to protect themselves from pesticide exposure. However, the large majority (79.4%) acknowledged that pesticides can cause health problems, and over half o f them (54%) indicated they have some concern that they have become sick from being exposed to pesticides (McCauley et al., 2002) In North Carolina Latino farmworkers varied noticeably in the amount of safety training received and the adoption of safety prac tices. Perceived lack of control w as a relevant factors that decreased workers use of safety practices (Elmore & Arcury, 2001) In an other study with farmworkers in the US (Salazar et al, 2004) workers recognize d the importance of protective behavior but they d id not comply with recommendations. They mentioned feeling hot and uncomfortable when wearing protective equipment. Some farmworkers in the Middle East were found to be aware of the protective measures whose use is indi cated when applying pesticides (Yassin et al., 2002)

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98 Despite their knowledge about the adverse health impact of pesticides, the use of protective measures was poor. These findings show that knowledge is not the only factor controlling the decisions reached by individuals involved in agricultural work as far as the opportune adoption of protective measures and/or in relation to reducing pesticide use. Other individual factors influence protective behavior including beliefs, attitudes, and perceptions (Yassin et al., 2002) Perceived Risk and Control F armworkers are aware of the risks associated with pesticide exposure, and have f personal vulnerability. Some farmworkers have been found to perceive themselves as being more vulnerable to the harm produced by pesticides than others (Arcury et al., 2002; Salazar et al., 2004) In research performed with farmers and farmworkers in North Carolina, US, farmworkers believe d they have been exposed to pesticides because they experience symptoms during or after the application. Farmworkers believe d susceptibility to chemicals is because ideas often predict health behavior ( Quandt et al., 1998) Thus, when farmworkers fe lt were more likely t o adopt appropriate preventive measures and behaviors when confronting health threats as in the case of pesticide exposure (Vaughan & Fridlund Dunton, 2006) Another study performed with Latino farmworkers in the U.S. showed that they have a high level of attribu safety versus feeling personally responsible. Participants belie ved in the inevitability of work accidents because they are due to the will of G od Yet they also believe d their individual action s can reduce the probability of injuries (Grieshop et al., 1996)

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99 Previous work has indicated that farmworkers experience high levels of perceived risk from pesticides and low levels of perceived control of pesticide use and safety measures (Arcury et al., 2002) In a study of farm workers Arcury et al (2002) found that r eceiving information about pesticide safety reduced perceived risk and increased perceived control. However, perceived risk had a limited relationship to safety knowledge and was not related to safety behavior. Additionally perceived control was not related to pesticide exposure knowledge, but was s trongly related to safety knowledge and safety behavior (Arcury et al., 2002) These results demonstrate that for pesticide education to be effective, it must address aspects of control (Vaughan & Fridlund Dunton, 2006) Knowledge Attitudes and Beliefs A study performed among North Carolina Latino farmworkers showed that al though workers varied in their levels of knowledge regarding routes of exposure, specific health effects of pesticides, and ways to avoid and reduce exposure, there was a basic knowledge level on the deleterious effects of pestic ides on human health (Elmore & Arcury, 2001) In a study by Salazar et al (2004) with farmwor kers, s ome participants identified specific diseases that could be associated with occupational exposure to pesticides including cancer, skin disorders, high fever, asthma, and other allergic reactions (Salazar et al., 2004) Some f armworkers operate on the belief that they possess that pesticides will not affect them (Hahn & Inhorn, 2009) Focus groups interviews have revealed that farmworkers have developed an extensive body of lay knowledge, based on personal perceptions, about pesticides and pesticide exposure in cluding means of pesticide entry into the body and potential health effects of pesticide exposure (Elmore

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100 & Arcury, 2001; Flocks et al., 2007; Salazar et al., 2004) In the findings reported by Flocks (2007) farmworkers attribute d extreme weather conditions, inc luding hot and dry or hot and humid, as affect ing their bodies and ma king and more vulnerable to pesticide exposure and absorption. Nursery workers in Oregon described that the most common means of pesticide entry into their bodies include through skin and pores, inhalation and hand to mouth contact. Some of these nursery workers judged the importance of pesticide odor itself (not necessarily the chemical compounds in it) as causing physical symptoms such as dizziness, nausea, sneezing, head aches, allergies and coughing (Flocks et al., 2007) The mos t familiar health problems identified by participants included headaches, general itching, rashes, swollen hands, and allergies. They believed that long term exposure to some pesticides could cause sterility in men and infertility in women (Flocks et al., 2007) In the Gaza Strip, farmworkers reported high levels o f knowledge on the health impact of pesticides (97.9%). Moderate to high levels of knowledge were recorded on toxicity symptoms related to pesticides (Yassin et al., 2002) The Case of Colombia In Colombia the situation related to pesticide use for agriculture is multifaceted and difficult to assess The country is marked by sociopolitical instability, extreme poverty, rampant violence and corruption and a rather strong influence of pr i vate capital and private interests in the design and implementation of public policies (Cardenas, 2005; Sanmiguel Valderrama, 2007) T his situation translate s into vague, weak regulatory frameworks in several for ms including work safety, labor right s and compliance with the management of hazardous materials from which pesticides are just an example (Castro, 2003)

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101 Farming is a major sector of the Colombian economy (Ministerio_de_Agricultura, 2011) The bulk of agricultural production is achieved by conventional means of cultivation with heavy reliance on the agro chemi cal industry (Ministerio_de_Agricultura, 2011) Regulation for pesticide use in Colombia exist s but they do not interpret the risks inherent to pesticide use exposure in terms of human and environmental health and are not fully or consistently enforced (Castro, 2003) For example, several pesticides that are banned in other countries are still used in Colombia (Cardenas, 2005; MinisteriodeSalud, 2010; Nivia, 2000) Additionally the cut flower industry, a strong component of national agribusiness, with multi million exports annually, is depend ent on the inten sive use of synthetic pesticides and fertilizers putting a large portion of the population of agricultur al workers and their communities at high risk (Sanmiguel Valderrama, 2007). In Colombia pesticide use and exposure is widespread (Nivia, 2000) Individual factors have been scantily studied finding limited knowledge about harmfulness of pesticides among campesino communities They perce ived risk associated with pesticide use and exposure but they do not adopt protective measures because of power relations with their bosses and social discrimination (Sanmiguel Valderrama, 2007). This study aims to e xplore how campesino non pesticide users differ in their knowledge, attitudes and beliefs, and perceptions of control and confidence surrounding pesticide use compared to pesticide users. The research question in this study was: What are the attitudes, bel iefs and risk perceptions of campesino pesticide users and agroecological adherents in San Cristobal and how do they differ in these findings?

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102 Research Setting San Cristbal is a corregimiento (Rural Division) in the municipality of Medellin (Central Anti oquia, Colombia). It includes the head of the township and 17 veredas (rural subdivisions) (Medellin, 2010) ten of which were selected for data collection in this pr oject as follows: El Patio, El Llano, Las Playas, La Cuchilla, La Palma, El Carmelo, Travesas, Yolombo, El Uvito, and San Jos de la Montaa. The head of the township is located 11 miles from downtown Medellin, and San Cristobal maintains strong economi c, commercial, and administrative ties with Medellin. (For location and characterization of the study site refer to Figure 3 1, 3 2, and 3 3 in Chapter 3). Agriculture constitutes the main economic activity in San Cristbal including cut flowers, and a b road range of vegetables San Cristbal ranks as the largest horticultural rural division of Medellin and functions as a major source of produce to the latter (Medelli n, 2010) Methods This study was based on quantitative methods. In this section I describe the characteristic s of participants, participant recruitment process, steps for the administration of the instrument, data analysis, and human subjects. Participa nts All participants involved in this investigation worked in agriculture and many of them combined this occupation with other partial jobs. Most of the participants were married (74.68%) adult males (54.43%) who have worked in agriculture for a significan t period (average ~36 years in the field). The average age was 53 years. The average amount of years of education was 6.15 (Std. Dev. 3.82). All the demographic information is described in Table 3 1 ( C hapter 3 ) The total sample of campesinos was

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103 79. Out o f this number, 43 (54%) were only pesticide users, 15 (19%) were in the transition stage in which they still used pesticides but they were slowly introducing agroecological practices to a portion of the land they cultivate, and 21 (27%) were campesinos wh o had already changed completel y to agroecological practices. For the analysis I put together the transition group with the agroecological group in the same non users group and named it agroecological adherents I provided f urther detail on these topics in Chapter 3. Sampling and Participant Recruitment This project used a purposive sampling strategy, which consisted of purposefully selecting participants who would best help to understand the problem and provide information pertaining to the research quest ion (Creswell, 2009) The first step was to contact community leaders through personnel at the nongovernmental organization Corporacin para la Investigacin y el Ecodessarrollo Regional (Corporat ion for Research and Regional Ecodevelopment) (CIER ). I attended several community action board meetings (Juntas de Accion Comunal, described in detail in methods section, Appendix D ) in some of the rural subdivisions including Travesias, San Jose de La Mo ntaa, El Llano, and La Palma in order to present the project and contact possible participants. Cognitive Interviews In this study I performed two cognitive interviews with campesinos to refine the instrument (Appendix C). I asked respondents to think a loud as they attempted to answer questions. This technique helped to identify problems with questions and indicated possible solutions (Drennan, 2003) The only confusion for participants was related to the initial 5 item Likert scale designed to measure attitudes and beliefs about

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104 pesticide harmfulness to human health and the environment, and usefulness of pesticide s in crop production (see Appendix C ) This scale originally went from strongly agree to strongly disagree. After completing the cognitive interviews I simplified the scale to three items: yes, neutral, and no Board of Directors Meeting I also attended the board of directors meeting of Associacin Campesina Agroecolgica de la region de Boquern Corregimiento San Cristobal ( Campesino Agroecological Association of the Boquern ) (ACAB). This association of campesinos works on different activities and at different le vels with their associates including: education and training about agroecological practices, the planning of their harvest, technical support with the management of their crops, and organization of crop marketing, among others (ACAB, 2012) I went to this meeting with the aim of presenting the project to ACAB leaders and obtaining permission to contact campesinos who belong to this association and constituted the sample of the non pesticide users. Que stionnaire Administration I constructed the questionnaire based on the following components: questions about attitudes and beliefs in a 3 item likert scale (Jamieson, 2004) (e.g., pesticides a ffect my health, pesticides can affect water ), question s about pesticide decision making in a 5 item scale (e.g., when you decided to use pesticides, did you think it was a very good, good, neither good or bad, bad or very bad decision?) perceived control about stopping pesticide use (the response options were on a scale of 1 10 ) ( the question was: i f you decide you want to stop using pesticides, how much control do you think you have? ) perceive confidence about stopping pesticide use (the response option s were on a scale of 1 10 ). (the question was: i f you wanted to stop using

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105 pesticides how confident are you that you could stop ?) and demographic information. ( T his instrument is in Appendix C). The first round of questionnaires occurred with the initial campesinos (seeds) contacted through CIER assistants. Following these initial questionnaires, I asked each contact to provide names and phone numbers of two or three neighbors. I used convenience sampling (Creswell, 2009) and s now ball sampling techniques (Bernard, 2006) i n this portion of the study. The reading level of the informed consent and questionnaire forms was appropriate for the target audience ( fifth grade level ). Data Analysis This study included 79 questionnaires. We filled out the questionnaires o n paper entered data into Excel 7 program sheets, and saved the data on a computer. I analyzed the data using SAS 9.2 software. I stratified data by pesticide user (n = 43 ) or non user (n= 36 ) The semi structured portion had scales that provided ratings. I processed and analyzed the s tatistical data using SAS 9.2 (Delwiche & Slaughter, 2008) Analysis encompassed the following steps: 1) descriptive s tatistics for each item, 2) analysis of principal components of the scales to determine structure, 3) Chi square tests to compare the groups (pesticide users and non pesticide users) across categorical variables, building of a score of probability for que stions 1a 1n (attitudes and beliefs), 4) performing logistic regression analysis to examine the relationship between pesticide use and the variable s confidence and control, 5) calculating internal (Cozby, 2009) for attitudes and beliefs, 6) running Spearman correlation coefficients to detect linear correlations between variable 1a 1n

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106 and 7) running logistic regression analysis with a dichotomized vers ion of perceived pesticide harm. Human Subjects I distributed and read out loud the informed consent in Spanish to the participants Participants signed the inform consent form before the questionnaire started. T he research assistant and I read a ll questionnaires in Spanish to participants and filled them out in the ir presence. We administered the q uestionnaires to the members of the family (e.g., husband and wife) in the same visit but in separate rooms so as to maintain the confidentiality of the information. We conducted a ll questionnaires i n a private present. Data were questionnaire had a unique code number to protect the privacy of participants. I kept t he list of names that connected the respective codes of participants in my office with double locked security. Results Below is a description of the analy sis and results from an explor ation of the following individual factors among participants: attitu des and beliefs related to pesticide use, decision making about pesticide use, perceived control about stopping pesticide use, and perceived confidence about stop ping pesticides use. I described and compare d the findings between pesticide users and non us ers. I report the findings in the following order: descriptive, bivariate, scale development, and multivariate. Descriptive I did descriptive statistics of each item to determine the nature normal distribution s The descriptive statistics for demograph i c information is described in C hapter 3.

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107 Decision s about p esticide u se To evaluate campesinos perception s about how good or bad the pesticide decision was I provided a L ikert scale with the following question: When you made the decision of using pestic ides, do you think this decision was: 1=very good; 2=good; 3=neutral; 4=bad; 5=very bad. I did descriptive statistics to see the frequencies of responses. Most campesinos expressed that pesticide use is very good (35.9%) or good (28.1%). A minority co nside red it to be bad (16.67%) ( Table 4 1 ) Therefore it was clear that pesticide use was accepted in this community and it was considered to be something very good or good by the majority of participants. Bivariate Analysis Perception about pesticide harm I wanted to determine if non pesticide users have a diminished perception of the dangers and deleterious impacts of pesticide use and exposure on human health and the environment compared to pesticide users. To answer this question I built a score of probabi lity for questions 1a 1n (attitudes and beliefs). This score was based on the questions of attitudes and beliefs and reflected the level of perceptions of impact of pesticide use on health and the environment. Small values of this score are related to high levels of perception of health and environmental impact of pesticides (pesticide use affects human health and the environment). I confirmed t his idea using a logistic regression model to check the variables perceived pesticide harm (single predictor vari able) related to pesticide use ( categorical outcome variable which translates into use or not of pesticide s ). With a p value of 0.0007 these variables were strongly associated.

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108 I calculated a Receiver Operating Characteristic (ROC) curve 1 and the value was: 0.776 and the model adjusted well. The likelihood compared the variable with a model that does not have the variable (null model, just intercept model). The effect size was measured as (0.205 1) x 100% = 79.5% which means that an increase in one uni t in the score of perceived pesticide harm decreases the logit of using pesticides by 79.5%. Perceived c ontrol C ampesinos were asked to rate their perceptions on their level of control to stop pesticide use on a scale of 1 ( no control ) to 10 ( extreme control ) Out of the total sampled population, 26.5 % responded perceiving no control to stop ping pesticide use. However 33% of participants respon ded perceiving maximum control ( Table 4 2 ). Participants who perceive d maximum control were all non pesticide users. There is a clear difference between the amount of perceived control of pesticide users and non users. To explore if pesticide users perceive having less control to use pesticides than non users I ran a logistic regression analysis having the v ariable pesticide use as the outcome variable (dependent) and perceived control as the predictor variable (independent). I treated the variable perceived control as continues The result showed that the association between pesticide use and control was sig nificant (p value = 0.0004) which means that higher control decreases the probability of using pesticides. I 1 Receiver Operating Characteristic (ROC) curve plots the sensitivity against the false positive rate (i. e. one minus specificity) for a range of thresholds to help visualize test performance (Vittinghoff, Glidden, Shiboski, & McCulloch, 2005)

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109 measured the effect size as (0.2549 1) x 100% = 74.5 % which means that an increase in one unit in control decreases the logit 2 of using pesticid es by 74.5 %. Perceived c onfidence. To assess how much confidence campesinos perceive they have to stop the use of pesticides I used a scale of 1 ( no confidence ) to 10 ( extreme confidence ) Most participants (57.7%) perceived no confidence at all to stop pes ticide use. However some participants (16.7 %) expressed perceiving maximum confidence ( Table 4 3 ) It is important to clarify that the class representing perceiving maximum confidence was composed of agroecologist In other words, there is a clear differe nce perceived confidence between pesticide users and non users. To explore if pesticide users perceive having less confidence to use pesticides than non pesticide users I ran logistic regression analysis having the variable pesticide use as the outcome va riable (dependent) and perceived confidence as the predictor variable (independent). I treated the variable perceived confidence as continu ou s. The analysis showed that the association between pesticide use with perceived confidence was significant (p valu e: 0.0007), meaning that higher confidence decreases the probability of pesticide use I measured the effect size as (0. 3 5 20 1) x 100% = 64.8 % which means that an increase in one unit in confidence decreases the logit of using pesticides by 64.8 %. Pesti cide use with other variables I conducted Chi square tests to compare the groups of pesticide users and non users ( pest icide use ) with other variables. This variable, pest icide use was only significantly related with occupation ( p value=0.0494) 2 Logit refers to the log arithm of no using pesti cide versus using pesticide (log(p/(1 p)))

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110 and resid ence (p value =<.0001). It was borderline significant with age (younger than 53 years which was the median, p value = 0.0561). I dichotomized age in two categories: lower than 53 and higher than 53 (the median value). When I ran the test with age being con tinuous; I did not find association with pest icide use Scale D evelopment Perceived p esticide h arm I carried out principal components analysis (PCA) of the scales to visualize potential structure s I implemented a principal component analysis to reduce di mensionality from question s 1 a to 1n (attitudes and beliefs) In order to explain more variability I combined components 1 and 2 by using a weighted average that was used to create an individual score called perceived pesticide harm This score went from 4 2 (maximum score, when the participant answered no to all the questions) to 14 (minimum score when participant answered yes to all the questions). Large values of this score were associated with people who do not have a high perception of harm caused by p esticide use and exposure on human and environmental health. Because this perceived pesticide harm does n o t have a reference value, to assess 1 by using a logistic transformation. I called it perceived pesticide harm (logistic). I wanted to explore if these variables that measure attitudes and beliefs were inter related. For this, I use d alpha for variables that measu red attitudes and beliefs (1a 1n) Results indicated an alpha of 0.64 indicating that the correlations of each item with every other item were good, although not very strong. I checked the v alues of alpha deleting each item and only increased to 0.67 whe n variable e ( pesticides can affect the soil) was deleted.

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111 To see correlation between these variables, I ran Pearson correlation which just detects linear correlation. I also ran Spearman correlation which is very appropriate because it detects correlati ons when t hey are not necessarily linear. These correlations can be curvilinear. The most important correlation of the variables 1a 1n (attitudes and beliefs ) included: pesticides can harm ; p esticides can harm good insects with pesticides affected my health ; pesticides can harm the water pesticides pesticides can harm the water and using pesticides allows me to pro vide more for my family economically with pesticides make the crop look cleaner ( Table 4 6 ) Multivariate A nalysis Because perception of harm includes values between 0 and 1 I implement ed a beta regression model using this score as a response. It is imp ortant to observe that a high perception of harm (closer to 1) means that the person has an enhanced perception of pesticides being harmful for health and the environment. Only perception of harm was significant with age (p value: 0.0480) ( younger than 53 years which was the median ) and with residence (p value: 0.0097) (Table 4 4) Additionally I explored how the variable perceived pesticide harm depends on the other variables. For this, I conducted a logistic regression procedure with a dichotomized vers ion of the variable perceived pesticide harm as response (0 if perceived pesticide harm<0, and 1 if perceived pesticide harm>=0). Only perceived pesticide harm with age (younger than 53 years) was significant (p value: 0.0529, borderline significant) (Tabl e 4 5 ) This is crucial as it implie d that campesinos younger than 53 years have less of a perception of the degree of harmfulness of pesticides for

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112 human health and environmental than campesinos older than 53 years. It is important to clarify that in this analysis logistic regression works with perceived pesticide harm dichotomized. Discussion and Interpretations There was a consistent coherency in the results of parameters assessed between user and non users ( e.g. non users perceiving more confidence and control than pesticide users). This was an indication that both groups were well differentiated in terms of what it implies to use pesticides for human health. It also delineate d a characteristic pattern of acceptance of the conditions imposed from the out side (external, e.g., market pressure, social norm, etc.) in the case of the user sample vs. a commitment to confront the established dogma in the case of non user. Pesticide users largely believe that pesticides are not harmful for human health and the en vironment. In contrast, non pesticide users have a higher perception of the harmfulness of pesticides for human health and the environment especially among older participants (older than 53 years). Therefore, public health interventions in this pesticide u ser population should focus on increasing awareness about the harmfulness of pesticides for human health and the environment; this would be beneficial especially when targeted to younger community members. Non pesticide users perceive they have more contro l in relation to pesticide use than pesticide users. In the case of perceived confidence, most campesinos expressed having very little or no confidence to stop pesticide use. However, the few participants who perceived having high confidence were all non pesticide users. Having higher control and higher confidence decreased the probability of using pesticides.

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113 This study demonstrated that pesticide use for campesinos represents an environmental justice concern as was also found in a study carried out with farmworkers in the US (Arcury et al., 2 002) A basic principle of environmental justice is that local communities must have control over their environment. The environmental justice framework not only recognizes environmental injustice as it is associated with humans harming nature, but it als o recognizes that environmental injustice arises from class, racial, and gender discrimination (London, 2003; Taylor, 2000) For education on preventing/reducing pesticide use to be successful, it must address the crucial component of control over pesticide use. In pesticide use and safety education intervention s, campesinos should not only be told what they should do to reduce pesticide use and exposure but also why and how this behavior will decrease exposure and improve their health, i.e., building a clearer justification to explain behavior (Arcury et al., 2002) Subsequently, future public heal th interventions should be aimed at increasing perceived control and perceived confidence mainly among pesticide users. As a consequence, this could lead to greater behavioral change of decreasing pesticide use. In other words, the tools for community empo werment should be built with local communities instead of being brought in as an external set of adequate rules and procedures. Examples of achievement in the change of paradigm implied for the non users can serve as a valuable preliminary experience and a demonstration of how the problem of human health alterations and environmental degradation should have an interdisciplinary approach, for example in the conjunction of Agroecology, public heath, and human behavior.

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114 The individual factors that play ed a r elevant role in the decision making process of pesticide use include d entrenched, and often interdependent, sets of beliefs such as those related to pesticide use benefits (are nece ssary for crops, benefit crops ), low perceived control, low perceived conf idence, and low perception of pesticide harm for human health and the environment. Campesinos who adhere to these established categories were more likely to use pesticides ( Figure 4 1 ) Therefore, future public health interventions must include these compo nents in order to reduce pesticide use in this community. In terms of education, more programs and interventions are needed for campesinos who express the need and interest to learn more about the harmfulness of pesticides and the benefits of agroecologic al practices. Undoubtedly, this education must be accompanied by more support from stakeholders, institutions and the local government in order to provide sustainability in these processes of change. These interventions must not be limited to present pre m anufactured information. Rather, these programs must help affected communities to buil d an appropriate local knowledge so as to gain awareness, control, and confidence in the process for implementing behavioral change on pesticide use and exposure dynamic s. Moreover, future studies should attempt to use behavioral, environmental, and psychosocial measures to build a body of evidence with which to better understand the risk factors for pesticide exposure among agricultural workers ( Qu andt et al., 2006) Results obtained after statistical treatment of perceived pesticide harm are more than worrying. They imply that younger agriculture workers possess less of a concern on the detrimental effects of pesticides on their personal health, o n the health of the

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115 community around them, and, in general on the health of the natural environment on which the local community ultimately depends. T he new generation of campesinos may have a hard time reorienting their approach to agriculture, in the dir ection of abolishing pesticide use though agroecological practices, therefore imposing serious threats for the health of the rest of the community. This finding stress es the idea of reinforcing research projects, educational campaigns, and public health pr ograms among communities of agriculturalists in rural Antioquia where the adverse effects of pesticide use abuse are just beginning to be documented. Doing so, this will work in the direction of strengthening our prospects in the struggle for social and en vironmental justice. Research of this kind is limited in Colombia; therefore, more research is needed on different regions of Colombia with the aim of exploring in more detail the level of local knowledge, perceptions of risk and control beliefs and atti tudes related to pesticide use. Li mitations and Strengths of the S tudy A major strength of this study was that data were obtained directly from the population of interest and that two contrasting groups were compared, i.e., users v s agroecological adhere nts There is a possibility that the interviewer reading the questionnaires to participants may have occasionally influenced responses. Due to the sample size and the purposive sampling strategy utilized in this study, the results cannot be generalized bey ond the study participants. The results can only be applied in this geographic area in San Cristobal, and might vary from other areas of Colombia where population characteristics are different. Although these limitations were recognized, thoughtful plannin g of the questionnaire and training of the interviewer were designed to offset them.

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116 The project design was cross sectional, so that it was not possible to see if perceived pesticide harm, perceived control and perceived confidence actually determine beha vior. Further, this analysis relied on self reports ideas, beliefs, attitudes, and perceptions; difference between self reports and actual behavior are always possible. Finally the scales utilized to measure beliefs and attitudes, pest icide decision, perceived control and perceived confidence have not been tested or validated beyond this study. Conclu ding Remarks Non pesticide users perceive having more control in relation to pesticide use and exposure than pesticide users. In terms of perceived confidence, most campesinos expressed having very little confidence to stop pesticide use. However the few who expressed high confidence all fell in the agroecological adherents ( non pesticide users ) group Having higher confidence and higher co ntrol decreased the probability of using pesticides. More public health interventions and educational efforts should be targeted to increase perceptions of control and confidence in this population with the aim of reducing pesticide use and improving colle ctive heath conditions. Perceptions of control are strongly related to confidence ; therefore I recommend increased attention to public health and education interventions to improve confidence in order to gain control of the process for implementing change linked to pesticide use reduction. In relation to perceived pesticide harm, participants with a high er perception of pesticides being harmful for human health and the environment were less likely to use pesticides. Young campesinos have lower perceptions of harmfulness of pesticides for the human health and the environment than do the older ones. This finding shows that younger generations are being more influenced by pesticide use than older people.

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117 Furthermore, education al interventions should be directe d to the young population with the aim of increasing awareness about the harm of pesticides for human health and the environment. Campesinos who believe pesticides are necessary for their crops, and that pesticides benefit crop s (larger yields, bigger veg etables fruits); that present low perceived control, low perceived confidence, and low perception of pesticide harm for human health and the environment, were more likely to use pesticides. All these findings help better explain how factors at the individu al level influence human health related behavior specifically the pesticide use decision making process. Now, given the fact that sprayed chemicals migrate in the mass of air or are incorporated into the water bodies and further dispersed raises the quest ion as to what exten t this personal decision only affect s health problems linked to environmental health, actions at the individual level determine to a large extent the health statu s of the community. San Cristbal is one of those cases where individual and collective perceptions on pesticide use and exposure recreate a collective ambience marked by the use of pesticide s affecting the lives of agriculture workers and non workers alik e. Moreover, future studies are needed to fully comprehend the unique occupational health and safety needs of these campesinos. Additionally, future studies should introduce long term and well structured public health interventions to increase awareness about the harmfulness of pesticides on human health and the environment with the aim of promoting behavior change in relation to pesticide use reduction.

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118 Pesticide use and exposure continue to be pressing public health and environmental problem s in rural C olombia that deserve serious consideration. The will to collaborate in this project manifested in the practice by both groups (users and agroecological adherents ) and by the community at large is evidence that successful research action and hence publi c health programs can be achieved with the community, by the community and for the community.

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119 Table 4 1. Frequency of pesticide decision options. The decision to use pesticide was Frequency Percent % Very good 28 35.9 Good 22 28.1 Neutral 9 11.54 Bad 13 16.67 Very bad 6 7.69 Table 4 2. Frequency of perceived control to stop pesticide use being 1 no control and 10 maximum control Perceived control Frequency Percent % 1 21 26.5 2 0 0 3 2 2.5 4 2 2.5 5 11 13.9 6 2 2 .5 7 0 0 8 6 7.6 9 2 2.5 10 33 41.7 Table 4 3. Frequency of perceived confidence to stop pesticide use being 1 no confidence and 10 maximum confidence. Perceived confidence Frequency Percent % 1 45 57.7 2 2 2.5 3 4 5.1 4 2 2.5 5 8 10.2 6 2 2.5 7 0 0 8 1 1.3 9 1 1.3 10 13 16.7

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120 Table 4 4 Beta regression procedure for estimating the odds of perceived pesticide harm as a function of variables like age, residence, occupation. Type of variab le Name or variable p value Parameter estimate Dependent variable Perceived pesticide harm Independent variable Age (younger than 53) 0.0480 0.2480 Independent variable Residence: Llano Other San Jos de la Mon tana Travesias 0.0097 0.1805 0.2054 0.1805 0.3219 Table 4 5 Logistic regression model for estimating the odds of perceived pesticide harm as a function of variables like age, residence, occupation. Only age was significant (borderline) Explanatory variable R square p value Indep endent variable : Age (younger than 53) 0.049 0.0529 (borderline significant)

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121 Table 4 6 Spearman correlation of variables 1a to 1n (beliefs and attitudes) The most important correlation s are included in this table. Variable Spearman coefficient p valu e a (pesticides affected my health) with j (pesticides 0.487 <.0001 b (pesticides help to produce more amounts of crops) with g (pesticides help to produce bigger size crops) 0.484 <.0001 c alth) with j ( p esticides can harm health ) 0.623 <.0001 d ( pesticides make the crop look cleaner) with i (pesticides help to sell the crop at the market) 0.443 <.0001 e (pesticides can harm the soil) with a (pesticides affected my heal th) 0.340 0.0022 f (pesticides can harm good insects. e.g. butterflies, bees) with a (pesticides affected my health) 0.539 <.0001 g (pesticides make the crop bigger) with b (pesticides help to produce more amounts of crops) 0.484 <.0001 h (pesticides c an harm the water) with j (pesticides can 0.688 <.0001 i (pesticides help to sell the crop at the market) with g (pesticides make the crop bigger) 0.464 <.0001 j (p esticides can harm health ) with h (p esticides can ha rm the water ) 0.688 <.0001 k (u sing pesticides allows me to provide more for my family economically) with d (p esticides make the crop look cleaner ) 0.503 <.0001 l (p esticides help to produce crops without worms ) with g (p esticides make the crop bigger ) 0 .424 <.0001 m (p esticides help to produce crops without skin marks on them ) with l (p esticides help to produce crops without worms ) 0.405 0.0002 n (pesticides help to produce crops without funny shapes) with i (pesticides help to sell the crop at the mar ket 0.405 0.0002

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122 Figure 4 1 Co n ceptual model describing the most influential individual factors in the decision making process of pesticide use in San Cristobal, Colombia. The most relevant components included beliefs (pesticides are necessary fo r the crops, pesticides are not harmful for human health and the environment and pesticides benefit crops making them bigger and in big amount), low perceived control, low perceived confidence and low perception of pesticide harm (for human health and the environment). All these factors increase the probability of using pesticides

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123 CHAPTER 5 CONCLUSIONS AND FURT HER RESEARCH Overview of the S tudy This research project was undertaken by documenting use and exposure behaviors among agricultural communit ies in San Cristobal, Antioquia (Colombia). The research questions were: (1) What are the primary factors associated with the use of pesticides and do those factors differ between pesticide users and agroecological adherents (2) How do campesino pesticide users and agroecological adherents differ in their attitudes and beliefs with regards to pesticide use and exposure? and (3) How do exposure? I implemented qualitative and qua ntitative methods in this investigation. The qualitative approach was guided by the ecological model. I used participant observation, interviews, and focus groups aimed at existing pesticide user s and agroecological adherents The quantitative approach use d questionnaires to derive demographic information, scale based evaluations of attitudes and beliefs, pesticides decision making, perceived confidence, and perceived control. Qualitative Findings The primary factors that helped to understand why campesino s in San Cristobal use pesticides in their agricultural practices included individual, interpersonal, economic, cultural and political levels In the individual level, factors that were most relevant included beliefs, attitudes and knowledge. Many pestici de users admit ted that they do not understand and are not well informed about the harmful, deleterious effects of pesticides for their health and the environment. Lack of adequate understanding

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124 demonstrates how pesticide use is rooted in human behaviors wh ich are in turn determined by a complex matrix of interrelated to factors such as habit s social norms, or cultural acceptanc e without a clear justification The most important categories in the Interpersonal factors level included family support and c ultural acceptance of pesticide use. E use. Many of those working in agriculture do not attempt to discontinue pesticide use ing everything and living within economic constraints receive financial support (e.g., government subsidies) during a transition from conventional (agrochemical based) to alternative agroecological practices, to guarantee their economic sur vival in case of crop failure due to extreme weather and pests, this would increase probabilities of change toward sustainable agroecological production. Campesinos who have changed to agroecological practices have experienced substantial economic losses. However, they do not experience this economic fear for an extended period because after approximately one year of difficulties they began to see the positive effects of agroecological practices on their crops, on the availability of food stuffs for family consumption and on the economy of the newly marketed organic products. Considering that the market profoundly influences pesticide decisions, more support of fair trade, agroecological markets is needed. Pesticide users believe pesticides are absolutely n ecessary for their crops. However non pesticide users have a clear idea that pesticides are not necessary for their crops and know other options from agroecology.

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125 The decision making process of pesticide use was mainly influenced by the following: low k nowledge about harm s associated with pesticides, the belief that pesticides are necessary for growing crops, negative attitudes to wards stop ping pesticide use, family influence toward s pesticide use, community pressure, market conomic fear, lack of government support, pesticide acceptance (social norm), negative community reaction when campesinos quit using pesticides, deficient policies and regulations about pesticide use and low use of protective equipment. Quantitative F indings Pesticide users mainly believe that pesticides are not harmful for human health and the environment. In contrast, non pesticide users have a higher perception of the deleterious effects of pesticides on human health and the environment. This is par ticularly true for older participants. Non pesticide users perceive they have more control in relation to pesticide use than pesticide users. In the case of perceived confidence, most campesinos expressed having very little or no confidence in their abili ty to stop pesticide use. However, the few participants who perceived having high confidence were associated with no t using pesticide s Having higher control and higher confidence decreased the probability of using pesticides. The individual factors that play a relevant role in the decision making process of pesticide use include beliefs such as pesticides are necessary for crops, and pesticides benefits crops (bigger sizes and amounts); low perceived control ; low perceived confidence ; and low perception of pesticide harm for human health and the

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126 environment. Campesinos who presented these characteristics were more likely to use pesticides. R esults obtained after statistical treatment of perceived pesticide harm are disquieting They imply that younger ag ricultur al workers possess less of a concern about the detrimental effects of pesticides on their personal health, on the health of the community around them, and, in general on the health of the natural environment around them on which the local community ultimately depends. Strengths and Limitations A major strength of this study was that data were obtained directly from the population of interest and that two contrasting groups were compared, i.e., users v. agroecological adherents There is a possibili ty that the interviewer reading the questionnaires and interviews to participants may have occasionally influenced responses. Due to the small sample size and the purposive sampling strategy utilized in this study, the results cannot be generalized beyond the study participants. The results can only be applied in this geographic area in San Cristobal, and might vary from other areas of Colombia where population characteristics are different. Although these limitations were recognized, thoughtful planning of the questionnaire and interview questions and training of the interviewer were designed to offset them. The project design was cross sectional, so that it was not possible to see if the factors at different levels and the variables measured actually dete rmine behavior. Further, this analysis relied on self reports of the different factors of the ecological model ; difference between self reports and actual behavior are always possible. Finally the scales utilized to measure beliefs and attitudes, pesticide decision, perceived control and perceived confidence have not been tested or validated beyond this study.

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127 Future Studies and Public Health Interventions More educational interventions would be beneficial among the pesticide user population in order to bet ter understand agroecological practices with the aim of reducing, or ideally eliminating, pesticide use. These educational activities could be agricultural community teach each other (Sanchez Morales, Ocampo Fletes, Snchez Hernndez, & Martnez Saldaa, 2008). Some campesinos in these veredas have lived in the same geographic region most of their lives and have been able to stop or reduce pesticide use. If the same communi ty members show their examples and the ways they have worked to be able to survive doing agroecology, these messages will be better received and assimilated by the other campesinos There are short term and long term solutions to be considered in this fiel d A p ublic health intervention that could be done in the short term would be to focus on integrating simple additional protective practices such as the use of plastic aprons that cover the front and the back of the campesinos when spraying. Additionally it would be beneficial to have wives use plastic gloves when manually washing the clothing of their husbands utilized during pesticide spraying. Such products could be provided free or at a nominal cost. Studies related to pesticide use and exposure shou ld be performed under a multidisciplinary approach involving different areas of public health including epidemiology, environmental health, behavioral sciences, biostatistics, and health services research. Such an approach would provide relevant informatio n that can be used in important public health interventions and could have better outcomes at the local, regional and national level.

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128 Future studies should be culturally appropriate to approach facts of social acceptance of pesticide use and try to implem ent intervention that can modify this norm. One way to target social norms existing about pesticide use in this community would be to use the Diffusion of I nnovation theory (DOI) (Rogers, 1995) to better understand the factors that influence the process through which a new innovation ( b ehavior, idea, technology) is incorporated into a community and is (or is not ) adopted. Diffusion is the way by which an innovation is communicated through various channels over time among members of a social group with the objective of maximizing reach an d exposure. The innovation is the technology or behavior that is perceived by the target population as new (Rogers, 1995) In this case the innovation would be the reduction or elimination of pesticide use in this community though the implementation of agroecological practices. This theory has already been used to categorize adopters of different agricultural practices to implement technologies such as hybrid crop strains (Rogers, 1958) A specific route of dissemination is co nceived by the DOI theory and is based on the following key processes: innovation development, dissemination, adoption, implementation and maintenance (Edberg, 2007) One additional concept to the DOI theory is that innovations are adopted in a staged process by various categories of adopters: early adopters, early majority adopters, late maj ority adopters and laggards. Identifying these groups within a target population can help in planning groups specific dissemination strategies (Edberg, 2007) Future research should be performed to identify these types of populations among campesinos in San Cristobal so that dissemination strategies can be targeted specifically for each grou p with the aim of having better success in the adoption of

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129 agroecological practices. Also it would be important to investigate the different categories of adopters among non pesticide users with the aim of understanding if they are characterized by a parti cular type of adopter that facilitated the implementation of agroecological practices among them. Future studies should also explore the diffusion context of this population because there may be political or social structures in this campesino community th at inhibit diffusion of a new behavior. Future studies could also be guided by behavioral theories such as Social Learning Theory (SLT) and the Theory of Planned Behavior (TPB). The main constructs of the SLT include: self efficacy behavioral capability, expectations, expectancies, self control, emotional coping, vicarious learning, situation, reinforcement, and reciprocal determinist (Edberg, 2007). This theory could further explore confidence characteristic of this population and aspects of the social n orm about pesticide use mentioned earlier. Public health interventions should have the goal of improving confidence, which could possibly be reflected in a reduction of pesticide use among this population. The TPB has the following constructs that help to explain behavior : attitudes, subjective norm, behavioral intention, perceived behavioral control, and perceived power. C ampesinos may know some of the harms related to these substances but they will not take action to reduce the risk when they feel that th ey have no control over their work situation The re fore, TPB should help to understand how other constructs might be connected with perceived behavioral control and can strongly influence pesticide use behavior Future public health interventions should tr y to increase perceptions and consciousness about pesticide harm, and decrease the belief that pesticides are good

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130 for the crops and the negative attitudes that without pesticides agriculture is not feasible. This way, a reduction in pesticide use in this community could be attained. Reduced perception of pesticide harm to human health and the environment stress the idea of reinforcing r esearch projects among communities of agriculturalists in Antioquia where the adverse effects of pesticide use abuse are ju s t begin ning to be documented. Doing so works in the direction of strengthening our prospects in the struggle for social and environmental justice. Public health interventions in the pesticide user population can focus on increasing awareness about the harmfulness of pesticides; this would be beneficial especially when targeted to younger community members and ideally guided by a community participatory approach with the aim of working with the guidance of the community, and for the benefit of the commu nity. This way the processes can be more sustainable. Additionally, public health interventions could try to bring factual information to modify the beliefs that pesticides are necessary for the crops. These interventions should also try to modify the nega tive attitudes to stop pesticide use so campesinos can be more positive about reducing this use. Economic support from the Colombian government and an explosion of agroecological markets (even orchestrated from the consumer side trough an increase in dema nd) could also facilitate the decision making process of these campesinos to stop pesticide use Public health interventions must be performed to increase awareness of this pesticide use issue among different stakeholders that play a big role in the reali ty of pesticide use. These stakeholders could be members of the different market groups ( agroecological adherents and pesticide promoters), NGOs like Penca de Sabila and

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131 Colyflor, and consumer groups among others The main group to be targeted in this typ e of interventions is the consumers group so a clear deman d of agroecological products increases. As a consequence, the market for agroeocological products would be stronger. With this participation the process can have bigger impacts and more continuity i n the community Finally more quantitative research must be performed exploring various health effects in this population including cholinesterase levels, prevalence of birth defects, spontaneous abortion rates, infertility rates, signs of early puberty a mong girls and boys, neurodevelopment and cognitive levels in children population, and prevalence of pesticide related symptoms (headaches, dizziness, nausea, vomit, convulsions, among others) A comparison of all these finding between campesino pesticid e users and agroecological adherents would have paramount importance considering this could represent clear evidence of the degree of pesticide exposure between these two groups. Policy Implications At the policy level policy makers must incorporate new laws and regulations in which some pesticides still in use (e.g., aldicarb, and paraquat) could be banned. The local and national government should be mo re vigilant about law enforcement s This law enforcement might be achieved through strict supervision from stakeholders, minister of health and minister of the environment. This supervision can be performed once a month in each household including personal pr otective equipment education. This protective equipment would be required to be provided by the loc al government for free to all pesticide user campesinos.

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132 Work at the policy level is important to improve regulations and supervision in regards to safe use practices. These campesinos ought to have periodic visits from professionals (e.g., agronomist, nu rses, medical doctors, and public health personnel), and governmental agencies like the department of health to supervise safe pesticide practices and also to make sure regulations are being followed. This can help to im prove the use of adequate personal p rotective equipment (PPE). Future studies combined with such policies are required to fully comprehend the unique occupational health and safety needs of these campesinos. The necessity of more policies exists so as to promote and support agroecological pr actices in this region with the aim of reducing pesticide use. Summary Findings of this study suggest that when participants had beliefs associated with the idea that pesticides are not harmful for human health and the environment, had fear and negative at titudes to stop pesticide use, live d surrounded by social norms that promote pesticide use, experience d community acceptance of pesticides, experience d experience d l ack of government subsidies for agriculture, an d low perceived control and confidence were more like l y to use pesticides in their agricultural practices. Future research and public health interventions ought to incorporate the different areas of public health including epidemiology, environmental heal th, behavioral sciences, and health services research and policies in order to have an integral approach of the pesticide implications in these campesino communities. Future studies must also deeply explore health effects related to pesticide use including neurologic and

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133 developmental alterations, reproductive and early puberty conditions, and prevalence of pesticide related symptoms in agricultural populations locally, regionally and nationally. The local and national government must create additional laws to better control the types and preparations of pesticides and be mo re vigilant about law enforcement s This w ork at the policy level is also important to improve regulations and supervision in regards to safe use practices and use of personal protective equipment More policies that promote and support agroecological practices in this region with the aim of reducing pesticide use are needed.

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134 APPENDIX A INTERVIEW GUIDE Part 1. General Information 1. Tell me about your life in this vereda. Probe: a. How i s your life here? b. Your family? c. Your community? d. In terms of health and economy? 2. In general, how do you perceive your health? Why? Probe: how is your health? 3. What do you do for a living? 4. I would like to ask you about your work in agri culture Probe: a. how long have you been doing agriculture? b. what crops do you grow? c. can you tell me about it? 5. Is this land where you work yours or you do work for someone else? Part 2. Knowledge About Pesticide Use 7. Can you tell me what have you heard about pesticides? Probe: a. What they are used for? b. Why are they used? 8. What were you told about your need to use pesticides? Probe: are they necessary or not? 9. What were you told about the bene fits of using pesticides for your crops? Probe: a. What type of benefits do you get from this use? b. What type of harms do you get from this use? 10. Thinking back who told you this information? essional

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135 Part 3. Pesticide Use 11. Do you use pesticides (synthetic/chemical) in your agricultural practices? Probes: a. Why? b. Why not? If yes, ask Question 12, if no, skip to 13. 12. How do you use pesticides in your work? Probe: a. How oft en do you use them? b.Tell me some names of pesticides you use. c. Do you use protective equipment when you use the pesticide? Why? d. Have you had any training on protective measures? 13. I would like to ask you about the use of pesticides in your commu nity, how common is it? Probe: a. Who uses pesticides in your community? b. How do they use them? c. How long have they been using them? 14. What do you think about the use of pesticides in relation to your personal health? Probe: a. Do you think it affec 15. What do you think about the use of pesticides in relation to your family health? 1 6. Tell me about the use of pesticides in relation to the natural environment. Probe: a. Do you think they affect the water? Why? b. Do you think they affect the soil? Why? c. Do you think they affect other animals? Why?

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136 17. Do you think the use of pestic ides negatively affect things in the natural environment in? Why? Probe: water, soil, and other animals. Part 4. Decisions Making About Pesticide Use 18. a. What do you think about your decision to use them? Pr obe: Is it an easy decision, are there any difficulties? b. What influence your decision to use them? Probe: was it up to you? Did you feel any pressure from anyone or anything? c. Do you think you can decide to stop using pesticides at any time ? Why? Probe: What do you think would be like to not use pesticides? 19. a. What do you think about your decision to not use them? Probe: Is it an easy decision, are there any difficulties? What influence your decision to not use them? Probe: was it up to you? Did you feel an y pressure from anyone or anything? c. Do you think you can decide to start using pesticides at any time? Why? Probe: What do you think would be like to use pesticides? 20. How helpful do you think the use of pesticides is in your crops? Probe: a. Do y ou think you produce better crops? b. How important was this idea in making the decision to use pesticides? 21. Do most people around you approve the use of pesticides? why? Probe: your family, friends, community approve the use of pesticides?

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137 22. Think 23. What do you think the future in this vereda will be like? 24. Do you want to add anything else?

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138 APPENDIX B FOCUS GROUP GUIDE Part 1. General Information 1. Tell me about your life in this vereda. Probe: a. How is your life here? b. Your family? c. Your community? d. In terms of health and economy? 2. What do you do for a living? 3. I would like to ask you about your work in agriculture Probe: a. how long have you been doi ng agriculture? b. what crops do you grow? c. can you tell me about it? Part 2. Knowledge About Pesticide Use 4. Can you tell me what have you heard about pesticides? Probe: a. What they are used for? b. Why are they used? 5. What were you told about your need to use pesticides? Probe: are they necessary or not? 6. What were you told about the benefits of using pesticides for your crops? Probe: a. What type of benefits do you get from this use? b. What type of harms do you get from this use? 7. Thinking back who told you this information? Part 3. Pesticide Use 8. Do you use pesticides (synthetic/chemical) in your agricultural practices? Probes: a. Why? b. Why not? If yes, ask Qu estion 12, if no, skip to question 1 0

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139 9. How do you use pesticides in your work? Probe: a. How often do you use them? b.Tell me some names of pesticides you use. c. Do you use protective equipment when you use the pesticide? Why? d. Have you had any tr aining on protective measures? 10. I would like to ask you about the use of pesticides in your community, how common is it? Probe: a. Who uses pesticides in your community? b. How do they use them? c. How long have they been using them? 11. What do you th ink about the use of pesticides in relation to your personal health? 12. What do you think about the use of pesticides in relation to your family health? Probe: a. Do yo 13. Tell me about the use of pesticides in relation to the natural environment. Probe: a. Do you think they affect the water? Why? b. Do you think they aff ect the soil? Why? c. Do you think they affect other animals? Why? 14. Do you think the use of pesticides negatively affect things in the natural environment in? Why? Probe: water, soil, and other animals.

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140 Part 4. Decisions Making About Pesticide Use Yo 15. a. What do you think about your decision to use them? Probe: Is it an easy decision, are there any difficulties? b. What influence your decision to use them? Probe: was it up to you? Did you feel any pre ssure from anyone or anything? c. Do you think you can decide to stop using pesticides at any time? Why? Probe: What do you think would be like to not use pesticides? 16. a. What do you think about your dec ision to not use them? Probe: Is it an easy decision, are there any difficulties? What influence your decision to not use them? Probe: was it up to you? Did you feel any pressure from anyone or anything? c. Do you think you can decide to start using pesti cides at any time? Why? Probe: What do you think would be like to use pesticides? 17. How helpful do you think the use of pesticides is in your crops? Probe: a. Do you think you produce better crops? b. How important was this idea in making the decisi on to use pesticides? 18. Do most people around you approve the use of pesticides? why? Probe: your family, friends, community approve the use of pesticides? 19. Do you want to add anything else?

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141 APPENDIX C QUESTIONNAIRE Part 5. Attitudes and Beliefs 1 Interviewer: first I would like to ask you some questions about your beliefs related to the use of pesticides. For each statement tell me if you: Strongly Agree, Agree, Neither Agree or Disagree, Disagree, or Strongly Disagree. Question Yes Neutral NO a. Pesticides can harm my health 1 2 3 b. Pesticides help to produce larger amounts of each crop (more kilograms) 1 2 3 c. Pesticides can harm the health of pregnant women 1 2 3 d. Pesticides make the crop look cleaner 1 2 3 e. Pesticides can harm the soil 1 2 3 f. Pesticides can harm good insects. ( e.g. butterflies, bees) 1 2 3 g. Pesticides make the crop bigger 1 2 3 h. Pesticides can harm the water 1 2 3 i. Pesticides help to sell the crop at market 1 2 3 j. Pesticides can cause harm the h ealth of children 1 2 3 k. Using pesticides allows me to provide more for my family (economically) 1 2 3 l. Pesticides help to produce crops without worms 1 2 3 m. Pesticides help to produce crops without skin marks on them 1 2 3 n. Pesticides help to produce crops without funny shapes 1 2 3 2 Overall, when you made the decision of using pesticides do you think i t was a very good thing, good, neither good nor bad bad or very bad thing for you? a nd why? Very Good Good Neutral Ba d Very bad

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142 3 From the beliefs just mentioned above; For pesticide users: Which of these beliefs were more important in making the decision to use pesticides? For non pesticide users: Which of these beliefs were more important in making the de cision of stop using pesticides? 4 In the following question please indicate how confident do you feel. Goes between 1 and 10: (use card with lather) For pesticide users: If you wanted to stop using pesticides how confident are you that you could stop? E xtremely confident No confident For non pesticide users: If you wanted to start using pesticides how confident are you that you could start?

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143 Extremely confident No co nfident 5 In the following question please indicate how much control you think you have. Goes between 1 and 10: (use card with lather) For pesticide users: If you de cide you want to stop using pesticides, how much control do you think you have? A lot of control No control For non pesticide users: If you decide you want t o start using pesticides, how much control do you think you have?

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144 A lot of control No control 6. Demographics: ID number: _____ A. Gender:_______ B. Age:_ ____ C. Marital status: single ___ married ___ divorced___ cohabitates___ D. Place of residence: ___________ E. Occupation: ________________________ F. Level of Education: o Some elementary: grade:_______ o Completed Element ary o Some high school: grade: ________ o Completed High school o Some undergraduate: how many years: _________ o Completed Undergraduate

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145 o More than undergraduate : what __________ for how many years:_________ Children (From younger to oldest) Gender Age Helps in the field? Yes or not and why Child 1 Child 2 Child 3 Child 4 Child 5 Child 6

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146 APPENDIX D RESEARCH DESIGN AND METHODS Overview The research project was carried out in Colombia. I focused on a rural agricultural community at Co rregimiento San Cristbal (rural division), located in the municipality of Medellin, Antioquia Department. San Cristbal is one of 5 rural divisions in the municipality of Medellin. The project encompassed closely working with the community at 10 veredas ( rural subdivisions) within San Cristobal. The project brought in additional actors that play a fundamental role in shaping new forms of social organization and on promoting alternative ways in which agricultural activities have been developing in the regio n during the last decade. Specifically NGOs ( e.g. CIER, Penca de Sabila, and ACAB ) and alternative markets (fair trade and organic, e.g. Colyflor, REC A B), which are committed to fostering agroecological practices and conservation through education and kn owledge transfer programs that enhance local social conditions towards technologic, economic and food sovereignty. These institutions were instrumental in establishing the strong links with community leaders and the community in general, so as to make it possible to access and produce the wealth of information used in addressing the research problems delineated for this project. In the research strategy deployed for this investigation I combined qualitative and quantitative methods. The qualitative approa ch was based on ethnographic community participatory research, which used participant observation, interviews, and focus groups (Israel et al., 2005) and targeted active adult pesticide users (men and women). In addit ion, I provided new avenues to understanding the problems under scrutiny by integrating the ecological model (Edberg, 2007) and by establishing a research

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147 framework that encompassed sampling two distinct populations in the realm of pesticide use and exposure: users and non users. A distinctive feature of the ecological model is that, by prov iding means and theoretical tools to examine complex interrelationships that occur between humans and their environments at different levels (individual, relationship, community and society) it avoids limiting an investigation of this nature to personal in fluences on behaviors (Edberg, 2007; Salazar et al., 2004) I collected the data (Interviews and focus groups), I transcribed them and subsequently coded them b y themes using the N Vivo software. The quantitative strategy incorporated the collection and analysis of demographic information, questions about beliefs and attitudes involving Likert scales, and questions about confidence and control related to the d ecision making process of pesticide use or non use Quantitative data were analyzed using SAS 9.2 software. The methodology here delineated has not been implemented in Colombia and elsewhere in Latin America, despite of the fact that health status of rura l and urban populations in developing nations in the region are profoundly and directly affected by the use of, and exposure to, pesticides routinely used in conventional agricultural production. Approach Concurrent mixed methods of analysis of qualitativ e and quantitative data helped to identify key individual and socio cultural aspects that are useful in creating future research projects and future public health interventions. Qualitative methods used included participant observation, individual intervie ws and focus groups. The aim was to find common themes and categories that could help to explain the different factors associated with pesticide use.

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148 With this methodology I also started to establish long term interactions in research and education with the community, local Universities, such as University of Antioquia and Universidad Nacional, and local NGOs as the ones mentioned above. Introducing public health practices that result from participatory research efforts contribute to an increase in the c apacities of local groups to actively participate in the design and implementation of coherent interventions in public health. This approach provides practical means to investigate complex, multifaceted problems in the realms of public health human behavio r, and conservation. In the mean time I attempted to reinforce participatory exercises with local campesino communities and in collaboration with NOGs and academe. Such exercises can significantly contribute to increase awareness on the roles they played b y individuals at the local level in shaping health status in the community with respect to a practical issue, i.e., pesticide use and exposure Ultimately, with this approach I aspire to extend my research and professional efforts beyond the actual investi gation so as to promote behavioral change in relation to the use and exposure to pesticides, thereby encouraging the emergence of a desirable agrarian culture that changes conventional agriculture into agro ecological practices that serve both the people a nd the environment (two sides of the same coin). Research Setting San Cristobal is a corregimiento (rural division) in the jurisdiction of Medellin municipality. The head of the township is located 11 miles from downtown Medellin. San Cristbal corregi miento (rural divisin) includes the head of the township and 17 veredas: Naranjal, El Patio, Pedregal Alto, El Llano, Las Playas, El Picacho, La Cuchilla, La Palma, El Carmelo, Boquern, La Ilusin, Travesas, Yolombo, Pajarito, El Uvito, San Jos de l a Montaa and La Loma ( Medellin, 2010 ) In the year 2005,

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149 population in San Cristobal was estimated at ~35,000 inhabitants (~ 49% males and 51% females). Situated in the tropical Andes of Colombia with a mild climate, rich soils and plenty of superficial water distributed among a dense fluvial network, San Cristobal sustains intense agricultural practices, the majority of which are carried out by conventional, and agrochemical based techniques. Pesticides and chemicals co exist in San Cristbal. Agricultur e constitutes the main economic activity in San Cristbal including cut flowers, a large offer of vegetables, and fruit. San Cristbal ranks as the largest horticultural rural division of Medellin and functions as a major source of produce to a metropolita n area with a population close to 4 million. Livestock activities, also intensive in the use of petrochemicals, are another important factor in the economy of the township (Medellin, 2010) The 10 veredas included in the study were: El Patio, El Llano, Las Playas, La Cuchilla, La Palma, El Carmelo, Travesas, Yolombo, El Uvito, and San Jos de la Montaa All these veredas are the locus of important agricultural ac tivity. The veredas with more area dedicated to agricultural activity included el Llano (61.86%), Travesias (4 1.45%) and La Cuchilla (33.22%) ( Table D 1 ) Procedure Participants All participants had to work in agriculture although m any of them combine thi s occupation with other alternatives. Most of the participants were married adult males who have worked in agriculture for more than 35 years. I interviewed campesinos from 10 different veredas in San Cristobal (see list above). The average age of my parti cipants was 53 years. The average amount of schooling was 6.15 (Std. Dev. 3.82 years).

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150 Sampling and Participant Recruitment This project used a purposive sampling strategy (Creswell, 2009) whic h consisted on purposefully selected participants that would best help to tackle the research problem and the research question The first step was to contact community leaders through CIER personnel. I attended several community action board meetings in so me of the veredas including Travesias, San Jose de la Montaa el Llano, and La Palma in order to present the project and contact possible participants (each vereda has a community action board constituted by members and leaders with established homes in the rural subdivision). This board meets approximately once a month to discuss needs and problems at the local and regional level. Community participation started since the beginning of the project. A school teacher from the NGO called CIER in Medellin in troduced me to the first community leader in the vereda Travesias; this leader subsequently invited me to the first community action board meeting in which I presented the project. At that meeting, the assistants provided me with some telephone numbers of possible participants in the vereda. In this meeting the assistants provide further contact information (names, phone numbers, and addresses ) of friends in other veredas who could help me to contact their respective leaders. I called these other leaders an d they invited me to attend their particular community boards. I applied snowball sampling techniques in this portion of the study. Snow ball sampling is one of the nonprobability sample strategies and it has low external validity. On the other hand, when backed up by ethnographic data, studies based on this sample technique are highly credible (Bernard, 2006) In snowball sampling the researcher locates one or more key individuals and asks them to name others who would be likely candi dates for the specific research (Bernard, 2006)

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151 Snowball sampling is useful in studies of small, bounded, or difficult to find populations (Bernard, 2006) The snow ball sampling began during this initial componen t of the study. One of the campesinos in Travesias vereda ( rural divisions) who is also a c ommunity leader contacted another neighbor so that I could carry out the cognitive interviews. Cognitive Interviews Cognitive interviewing is a combination of cogn itive psychology and survey methodology, and has been developed to identify problematic questions that may elicit response error. Cognitive theory is used to understand how respondents perceive and interpret questions and to identify potential problems tha t may arise in prospective survey questionnaires (Drennan, 2003) Cognitive interviewing involves interviewers asking surv ey respondents to think out loud as they go through a survey questionnaire and tell them everything they are thinking. This allows understanding of the Cognitive interview s have been used in a number of areas in health care research to pretest and validate questionnaires and to guarantee high response rates. This type of interviewing has been found to be extremely effective in developing questionnaires for certain age and c in health surveys prior to distribution (Drennan, 20 03) In this study I performed two cognitive interviews with campesinos to test the instrument ( Appendix A and B). I asked respondents to think aloud as they attempted to answer questions. This technique helped to identify problems with questions and ind icated me possible solutions. These interviews helped to find few questions that needed to be paraphrased in order to be easy to understand by participants. The

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152 questions in the qualitative interview guide ( Appendix A) were clear and easy to understand by interviewees. However, some questions in the quantitative questionnaire ( Appendix C ) were confusing specially the ones in the section of attitudes and beliefs. The five categor y Likert scale used for the questions about attitudes and beliefs had five categ ories from strongly disagree to strongly agree and were hard to understand. Therefore the scale had to be reduced to three categories: yes, neutral and no. The participants of these cognitive interviews also provided recommendations about the food that sh ould be included in the grocery bag, provided after the interviews and the questionnaires, in order to be well received by participants. Board of Directors Meeting I attended the board of directors meeting of Associacin Campesina Agroecolgica de la regi on de Boquern Corregimiento San Cristobal (ACAB)/ Campesino Agroecological Association of the Boquern Region Rural Division, San Cristobal with the aim of presenting the project to the leaders of the association and obtaining permission to contact campes inos who belong to this association. The aim of contacting this group of campesinos was to invite them to participate in data collecting for the sample of non pesticide users. Interviews and Questionnaires The qualitative interview guide was built by the following components: general about harmfulness of pesticide use in relation to human health and the environment, decision making about pesticide use and comments about the future of life and the vereda. The questionnaire was composed of the following components: demographic information, scale to measure attitudes and beliefs associated with pesticide use, and

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153 10 item, ladder type scale to measure perceived control and p erceived confidence. A copy of the instruments is included in Appendix A, Appendix B and Appendix C. The main constructs used in this research include: knowledge about pesticide use, perceptions of pesticides (in relation to human health, in relation to th e environment, common use in community), decision making about pesticide use, attitudes, beliefs, control and confidence. Each construct has specific items associated with it. The instrument used for focus groups was the same one applied for the individua l interviews with few minor modifications, considering that most of the questions included in this instrument were relevant in group discussions. See Appendix B. The first round of interviews occurred with the initial campesinos (seeds) contacted through provide the names and phone numbers of two or three neighbors; a member of the research team called these campesinos or went directly to their homes. Snow ball sampling and co nvenien ce sampling techniques were used in this portion of the study. The eligibility requirement for participants was to be an adult over 18 years of age engaged in work on agriculture in one of the 17 veredas. Half of the sample was constituted by synth etic pesticide users and the other half by campesinos who were pesticides users before, but decided to shift to agroecological practices therefore reducing or eliminating pesticides as part of their agricultural work. The reading level of the informed cons ent and interviews forms was appropriate for the target audience (5th grade due to the fact that many campesinos only complete up to this level of elementary education). Once the new contact agreed to take part in the project, participants were visited in a mutually agreed upon time and location. First, the informed consent was

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154 given out and read to the participants; these forms were signed before the interview started. To the extent possible, interviews of the members of the family (e.g. husband and wife) occurred in the same visit but in separate rooms so as to maintain the confidentiality of the information. Interviews were conducted by two different researchers, the Principal Investigator (PI) and one field assistant. The selection of whether the PI or assistant would conduct an interview with a given participant was randomly decided by the principal investigator by fli pping a coin. se in each vereda where only the researcher and interviewee were present. At the end of the interview, each participant received a food bag in recognition for his or her efforts and was asked to provide the research team with names and telephone numbers of two other friends. All interviews were audio recorded lock access. Each interview received a code and number to protect privacy of participants. The list of names that c onnected the respective codes of participants was minutes, questionnaires 20 minutes and focus groups 2 hours. The response rate of participants was 100% and none of the pa rticipants abandoned the study. I described t he veredas included in the cognitive interviews, i ndividual Interviews, focus groups, and questionnaires in Table D 2. Data Analysis Overview I used interviews that included: open ended questions, semi struct ured questions, questionnaires with Likert type scales and demographic variables. These instruments

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155 produced both qualitative and quantitative data H owever, quantitative data was used in a supportive capacity to help explain findings from the open ended questions. The qualitative part helped to explain the reasons why campesinos use pesticides. The quantitative portion also asked questions about attitudes, beliefs, control and confidence but using scales of measurement that give a quantitative idea of the strength of these attitudes and beliefs and the amount of control and confidence expressed by participants. Qualitative The qualitative portion of the study helped to answer the first research question: Why do campesinos in this community use synthetic pe sticides for agriculture? What factors are associated with this use ? It also helped to answer certain aspects of the second research question: How do campesinos that belong to the agroecological adherents group differ in their attitudes and beliefs surrou nding pesticide use? This second question was heavily supported by the quantitative portion of the study as explained later. While there are many approaches to analyzing qualitative data, I used conventional thematic content analysis (Creswell, 2009; Green & Thorogood, 2004) (Green & Thorogood, 2004) Qualitative conventional content esearch method for the subjective interpretation of the content of text data through the systematic classification process of coding and (Hsieh & Shannon, 2005) I utilized the following steps to accomplish the content analysis: reading all transcripts thoroughly;

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156 deriving codes from the transcripts; naming codes based on words used by interviewees; sorting codes into broader c ategories and themes; organizing codes, categories and themes according to relationships among them; preparing definitions and examples for each code and category; and, repeating the process as necessary until the data were captured within the codes (Hsieh & Shannon, 2005; Richards, 2009; Richards & Morse, 2007) A product of this process was a code book that included larger categories with discreet codes within them. Once this code book was developed, the research assistant was trained to code data and inter rater reliability was established. The training consisted on meeting with the PI to transcribe the first group of five interviews together and to interpret what was the informati on contained in the transcription to start creating a first version of the codebook. The research assistant and the principal investigator met periodically to discuss findings and coding. To prepare the data for content analysis, the research team created separate files and sets for each interview question by group (campesinos who use and do not use pesticides). Data highlighting and manipulation was accomplished through the use of NVivo 8 a widely used qualitative data software package (Richards, 2009) I imported the word files with the transcribed attributes. I created free nodes with the initial codes and later tree nodes that showed more hierarchical organizations of findings. I created models out of the tree nodes to visualize themes and broader categories. This qualitative analysis process included the steps of descriptive, theme and analytical coding (Richards, 2009) The main constructs explored in this study included knowledge, perceptions about pesticides, decision making, attitudes, beliefs, control and confidence. They are listed in Table D 3

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157 Quantitative Quantitative data were stratified by pesticide user or non user. This part mainly answered the fourth research question: How do campesinos that belong to the agroecological adherents group differ in their attitudes and beliefs surrounding pesticide use? The semi structure d portion had scales that provided ratings. Statistical data processing and analysis was conducted using SAS 9.2 (Delwiche & Slaughter, 2008) Analysis of the quantitative data encompassed the following steps to answer specific questions: Question: how are the demographic c haracteristics of participants? To answer this I conducted descriptive statistics of each item, including age, gender, marital status, place of residence (vereda), occupation, years of formal schooling, amount of childre n with their age and if they help in the field or not. I did data cleaning and recoding. Question: How is the structure of the scale components?. I performed an analysis of principal components of the scales to determine structure. I implemented a princi pal component analysis to reduce dimensionality from question 1a to 1n (attitudes and beliefs). In order to explain more variability, I combined components 1 and 2 by using a weighted average that was used to create an individual score called perceived pe sticide harm Higher values of this perceived pesticide harm were defined as having a low perception of harm related to the use of pesticides on both human health and the environment. Because this perceived pesticide harm does not have a reference value to determine the meaning of the score, the score was mapped

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158 into the scale as 0 1 by using a logistic transformation. This new variable was called perceived pesticide harm (log). Question: Are there differences between pesticide users and non users in the ca tegorical variables? Chi square tests were run to compare the groups (pesticide users and non pesticide users) across categorical variables. The variable of using or not using pesticides was called pest use Question: Do no pesticide users have a stronger perception of the danger and negative impact of pesticides on human health and the environment compared to pesticide users?. I built a score of probability for questions 1a 1n (attitudes and beliefs). This score was based on the questions of attitudes an d beliefs and reflects the level of perceptions of impact of pesticide use on health and the environment. Large values of this score are related to high levels of perception of health and environmental impact of pesticides (pesticide use affects human heal th and the environment). I checked how this score ( score perception harm ) was related to pesticide use (pesticide user or non user) finding they were strongly associated. Question: Do pesticide users have less perception about the negative impact of pestic ides and the beliefs that synthetic pesticides do not affect human health and the environment? I checked how that perceived pesticide harm variable was related to pest use (which is use or not pesticide use) and we found that they are strongly associated. Question: Is there any relationship between the variable confidence and the fact that a campesino is a pesticide user? Chi square tests were run to examine the relationship between pesticide use and the variable confidence which was significant.

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159 Resear ch question: do pesticide users have less co ntrol than non pesticide users? Chi square tests were carried out to examine the relationship between pesticide use and the variable control. Pest use with control was significant as well. I wanted to k now which logistic model was identified to test associations with all the quantitative variables. A full logistic model was then used, which tested the associations of all the studied variables. In order to select a model I implemented a backward eliminati on procedure based on the higher p value. With this procedure two candidate logistic models were identified. The cut off value for p to be excluded were lower than 0.05. 1n (attitude s and beliefs) (Cozby, 2009) I performed Spearman correlations to detect correlations th at were not necessarily linear I undertook a logistic regression analysis with a dichotomized version of perceived pestici de harm as response (0 if perceived pesticide harm <0, and 1 if perceived pesticide harm >=0). The idea consisted on checking if perceived pesticide harm (dichotomized) depends on one of the other variables. I conducted ANOVA with perceived pest icide harm and the other variables to see relationships. I implemented a backward selection model based on the higher p value to see which variables were selected. Because perception of harm takes values between 0 and 1, it seemed re asonable to implement a beta regression model using this score as the response variable. It is important to note that a high perception of harm (closer to 1) means that the person has

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160 a stronger perception of pesticides being harmful for health and the env ironment. Using beta regression I implemented a backward selection model based on the higher p value. The model selects the variables that have the higher p value (above 0.05) and the other variables are eliminated. Human Subjects Institutional Review Boa rd 02 at the University of Florida (IRB 02) and the ethical committee from the Medical School at the University of Antioquia, Colombia, provided me permission to perform preliminary contact with the community during April 2011 and the full data collection with interviews and questionnaires from May to October 2011. I translated the informed consent and instruments into Spanish as part of the requirements of the IRB02 and the ethical committee from the Medical School at the University of Antioquia, Colombia. The protocol number is: 2011 U 0106. Methods Summary I focused on exploring group differences in the factors related to the pesticide use. I analyzed these differences both qualitatively (do different factors emerge in each group of campesinos?) and q uantitatively (are there significant differences among scores on knowledge, perceived harm, decision making, attitudes, and beliefs among groups?). I conducted individual interviews, focus groups and questionnaires in 10 veredas in San Cristobal, Colombia accomplishing a total of 76 Individual interviews, 79 questionnaires and 5 focus groups. Qualitative data was analyzed using NVivo software and quantitative data using SAS9.2 software.

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161 Table D 1. Agricultural activity in the veredas included in the stu dy. Name of vereda Percentage of land used for Agriculture (%) El Patio, 16.41 El Llano, 61.86 Las Playas, 27.5 La Cuchilla, 33.22 La Palma, 12.87 El Carmelo, 1.21 Travesas, 41.45 Yolombo, 7.72 El Uvito, 23.91 San Jos d e la Montaa 17.55 Table D 2. List of veredas included in the cognitive interviews, individual interviews and focus groups. Instrument Name of vereda Cognitive interviews Travesias Individual Interviews and questionnaires Travesias, El llano, San Jos de la Monta a, La Palma, El Patio, El Uvito, La Cuchilla, El Carmelo, El Yolombo, las Playas, and Focus groups Travesias, El llano, San Jos de la Monta a, La Palma, El Carmelo.

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162 Table D 3. List of constructs of the study with items used Constructs Items used Knowledge about pesticide What they are used for Need to use pesticides Benefits of pesticides Harm of pesticides Perceptions of pesticides: in relation to human health in relation to the environment comm on use in community Affects your health, wife, children Affects other animals, air, water, soil How common pesticides use in community? Decision making about pesticides Easy decision or difficulties What influence your decision Can you stop pesticide use any time Attitudes Pesticides are/are not harmful for human health Pesticides are/are not harmful for the environment Use of protective equipment Life using pesticides again Possibility of start/stop using pesticides Believes Pesticides affect human he alth Pesticides help to have better crops Pesticides affect the environment Pesticides facilitate crop marketing Pesticides improves family economy Control How much control you feel about stopping or starting pesticide use Confidence How confident you fe el about stopping or starting pesticide use

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171 BIOGRAPHICAL SKETCH She was born in Medellin Colombia and lived there until she finished M edical S chool at the University of Antioquia. She moved to Gainesville Florida with her husband and enjoyed family and academic life for 12 years tota l in this city She went back to Medelln in 2007 and became a professor of public health and preventive medicine at the Medical S chool where she had studied before. Being there she decided to undertake her PhD studies in the area of Public Health and move d to Gainesville again. After completing her PhD degree, she will go back to the University of Antioquia and will pursue an academic life as a professor and physician.