Agricultural Workers

LINKING PRACTICE & RES EAR C H SECTION EDITOR: SALLY L. LUSK, PhD , RN , FAAN Agricultural Workers lthough 2.9% of the labor force worked in farm occupations in 1992 (U.S. DLBLS, 1994), very little research has been conducted related to this worker group. Yet, their rate of injury is higher than any other occupational group (NSC, 1997). More than any other worker group, they experience multiple risks in all the categories of hazards, e.g: • Chemical-fertilizer, insecticides. • Biological/infectious-fungus, molds, and infections from animals and soils. • Physical-heat, cold, noise, and sun exposure. • Environmental/mechanical-slippery floors, unsafe equipment. hazards-stress • Psychosocial associated with weather and crop failures. Even with the recognition of their many hazards, the database related to injuries and illnesses for this population is woefully inadequate, indicating a need for surveillance programs. Obviously, from this list of hazards and the lack of information about illnesses and injuries, multiple needs and opportunities exist for A nurses to assist in reducing illness and injury in agricultural workers. Unfortunately, most of the farm workers in the United States do not receive services from health care providers knowledgeable about their risks. Although NIOSH established an Agricultural Initiative in 1990 to reduce injury and disease among agricultural workers and their families, its scope was limited. The NIOSH Initiative, OHN in Agricultural Community program, assigned 31 nurses in rural hospitals, clinics, and health departments in 10 states to provide illness and injury surveillance (Connon, 1993). Randolph (1993) described the role of the agricultural health nurse, but little data exist related to numbers of nurses providing these services. Because the majority of farms are owned and operated as family enterprises (U.S. Department of Commerce, 1997), services to farm workers will influence the health and safety of families-ehildren as well as adults. The two studies reviewed in this column provide examples of interventions with farm workers that could be implemented by occupa- ABOUTTHE Ms. McCullagh is Assistant Professor, DepartREVIEWER: ment of Nursing, North Dakota State University, and doctoral student, School of Nursing, University of Michigan. ABOUT THE Dr. Lusk is Professor and Director of the SECTION Occupational Health Nursing Program, DiviEDITOR: sion of Health Promotion and Risk Reduction Programs, The University of Michigan School of Nursing, Ann Arbor, MI. SEPTEMBER 1998, VOL. 46, NO.9 tional and environmental health nurses and demonstrate approaches tailored to this worker group. REFERENCES Connon, C.L., Freund, E., & Ehlers, J.K. (1993). The occupational health nurse in agricultural communities program: Identifying and preventing agriculturally related illnesses and injuries. AAOHN Journal, 41,422-428. National Safety Council. (1997). Accident facts, 1997 Edition. Chicago: Author. Randolph, SA, & Migliozzi, AA (1993). The role of the agricultural health nurse: Bringing together community and occupational health. AAOHN Journal, 41, 429433. U.S. Department of Commerce. (1997). Statistical abstract ofthe United States: 1997. Washington, DC: U.S. Government Printing Office. U.S. Department of Labor, Bureau of Labor Statistics. (1994). The American Workforce: 1992-2005 (Bulletin 2452, April 1994). Washington, DC: U.S. Government Printing Office. Sally L. Lusk, PhD, RN, FAAN A TRACTOR INJURY PREVENTION PROGRAM (LEHTOLA, 1993) Background Data from the National Safety Council (1997) indicate that machinery related deaths were the most common cause of deaths occurring on farms, accounting for 48% of mortalities. Based on data from the NIOSH National Traumatic Occupational Fatality database, tractor related fatalities account for the largest share of agricultural machine related deaths (69%), at about 130 farm fatalities each year in the United States, with rollovers accounting for more than half of these (Etherton, 465 LINKING 1991). NIOSH estimates that 71% of fatalities from rollovers in the United States could be prevented by use of rollover protective structures (ROPS) (CDC, 1993). In 1985, ROPS became mandatory equipment on new tractors. However, only about one third of the tractors in the United States are equipped with ROPS because either the tractor was manufactured prior to the 1985 ROPS requirement , or the farmer removed the factory installed ROPS. Although tractors can be retrofitted with ROPS, the cost of this equipment and its installation prevents many farmers from making this investment. Synopsis The aims of the FARM-TRAC (Tractor Risk Abatement and Control) program were to reduce tractor related fatalities and injuries. Program planners theorized that farmers who had accurate perceptions of the per sonal safety risks involved in operating a tractor would use rollover protective equipment on tractors at their own farms. Planners selected farmers in a two county area to receive the intervention, while another two county area served as a comparison community based on similarities in tractor accident data, economics , farming practices, topography, climate, and locat ion. The program included involvement of community stakeholders, including health professionals, farmers, engineers , FFA (Future Farmers of America) advisors, and manufacturers. A variety of educational activities for farmers and school children were offered, including a farm safety day, tractor operator training course, displays, and distribution of written materials. Sales of ROPS and tractor rollover fatalities were monitored in the intervention and comparison communities for a 2 year period. 466 PRACTICE & RES EAR C H Results of the intervention program were encouraging. Tractor fatalities in the intervention community fell by 18.4 fatalities per 100,000 tractors, while fatalities in the comparison community fell by a much smaller number (4.4 per 100,000 tractors) . Sales of ROPS were higher in the intervention community (l per 374 tractors) compared to the comparison community (l per 1341 tractors). Other positive changes that occurred in the intervention community included the development of an active farm safety coalition and establishment of an injury prevention program for farm children. Critique The TRAC-SAFE program effectively used several principles of community intervention to enhance program efficacy. The TRAC-SAFE program used community assessment to enhance program results in two ways: 1) results of a recent epidemiologic study were used to establish program goals and to select intervention and comparison groups; and 2) the intervention was tailored to the target group through use of educational methods to promote voluntary behavior change in this population that commonly resists regulation and government intervention. Faced with a large number of geographically dispersed and independently owned farm enterprises, the program used public health principles and public health agency funding to promote the adoption of healthy work behaviors . Because farming typically includes participation of farm family members of diverse ages, program activities were directed at farm youth as well as adult farmers. Finally, the program used a community based approach involving participation of equipment dealers, educational institutions and organizations , extension staff, and health professionals. The outcomes of the tractor injury abatement program were evaluated using a comparison group, strengthening the ability to attribute changes in safe behavior and fatality rates to the program. The project design had a number of strengths: • To decrease the chance of program diffusion into the comparison community, intervention and control communitie s were selected that were geographically remote. • A multidisciplinary group of community members with an interest in mitigating tractor related injuries were recruited to serve on the program advisory committee. • Pretests were distributed to randomly selected farmers by FFA members. This face to face method of recruiting study participants could be expected to increase the rate of participation of farmers, while the population based selection increased the representativeness of the sample and ability to generalize results. • Pretests and posttests of both the intervention and comparison communitites, enabling comparisons and increasing the ability to attribute changes to program activities. Several study limitations existed. ROPS require the conjoint use of a seatbelt to hold the operator in the zone of protection in the event of a rollover. However, studies of seat belt use among tractor operators suggested that frequency of this protective behavior is low in this group (Ambe, 1994; Kelsey, 1996). Failure to use seat belts conjointly with ROPS results in a significantly lowered level of protection for farmers. An intervention program aimed at reducing tractor related fatalities and injuries is effective only if it promotes use of ROPS as well as seat belts for tractor operators. However, AAOHN JOURNAL LINKING this study did not assess whether the sales of Raps included seat belts or whether seat belts were in use in the fatalities. Although a comparison of fatality rates between the intervention and comparison communities favors the intervention group, it is difficult to make conclusions about the effect of the intervention because the number of fatality events is relatively low over the short, 2 year evaluation period of this study. Continued monitoring of health statistics of these communities is required to study the stability of rate of fatalities and changes in rates over a longer period of time. The proportion of tractors not equipped with RapS does not accurately reflect farmer risk exposure (Kelsey, 1996). For example, indoor use and stationery use of tractors present minimal risk for rollover, while fieldwork is associated with a much greater risk. This TRAC-SAFE intervention project did not compare communities based on hours of tractor operation. Instead, the researchers used the more traditional measure of number of tractors, a less accurate assessment of exposure of farmers to risk of rollover. CANCER EDUCATION INTERVENTIONS FOR RURAL POPULATIONS (REDING, 1994) Synopsis Persons working outdoors, including farmers, are among those most at risk for developing skin cancer, owing to their high level of exposure to ultraviolet light. An epidemiological study by Monroe (1992) confirmed that skin cancers occur more often among farmers. A program by the National Farm Medicine Center in Marshfield, WI was developed to design skin cancer prevention interventions among rural agricultural populations. Results of SEPTEMBER 1998, VOL. 46, NO.9 PRACTICE & RES EAR C H focus group interviews held with 15 farm families in target communities revealed that farmers preferred educational materials brief and to the point, and farm families recommended bringing health information to the farm. Based on this information, an unconventional method of delivering cancer prevention information to farmers was created. In an intervention aimed to determine farmers' acceptance of a new method of service delivery, farmers in a selected Wisconsin county received cancer prevention information and a sample of sunscreen from veterinarians making routine farm visits for providing preventive livestock health services. In a comparison county, farmers received cancer prevention information by mail. Two months later, farmers in both counties were asked to rate the acceptability of receiving health information from veterinarians. Results showed that farmers in both intervention and comparison communities found that receiving information by a veterinarian was acceptable, at 86% and 66%, respectively. It is interesting that farmers receiving the unconventional intervention rated it acceptable more frequently than those receiving information by mail. Critique In this community based intervention program, developers assessed community interests and barriers using focus group interviews. The investment of time and resources in these interviews and their subsequent use in program design were rewarded with high rates of acceptance of an unconventional health care delivery method. The program planners actively recruited support from existing community organizations, including the veterinarian association and cancer society. This collaborative approach was reported to be highly successful, resulting in the development of new cancer education materials with a rural focus and recruitment of local veterinarians as health educators. However, unlike the RapS study (Lehtola, 1993), the impact of this program was not measured in terms of health outcomes or health behaviors. Consistent with program goals of evaluating acceptance of this unconventional approach, developers used participants' self reported satisfaction with cancer information services to evaluate the program. Future studies using comparison groups are required to evaluate the efficacy of this innovative program on farmers' health behavior and cancer morbidity statistics. Program acceptance was measured by mailed surveys to intervention and comparison communities. However, response rates for these surveys was low, at 37% and 20%, respectively. For unexplained reasons, farmers who responded to these surveys may have been the same ones who were predisposed to favor expanded roles of veterinarians or promotion of cancer prevention. This selection bias may have inflated the measured level of acceptance of this intervention strategy. Use of alternative evaluation techniques, such as telephone or face to face surveys, may have produced a larger response rate and enhanced the validity of measurement of acceptance. IMPLICATIONS FOR OCCUPATIONAL AND ENVIRONMENTAL HEALTH NURSES The National Institute for Nursing Research (1995) has identified promotion of health behaviors among rural populations and prevention of unintentional illnesses among agricultural workers as key elements 467 LINKING for effectively meeting the health care needs of rural Americans. The nursing role in agricultural health and safety has been expanding, with nurses in many practice settings providing occupational and environmental health services to agricultural workers. These settings include county and state health departments, rural clinics, hospitals, emergency departments, migrant health agencies, and workplaces where farmers supplement their farm income through off farm employment. Nurses interested in developing interventions for agricultural workers might consider applying some of the approaches described in the reviewed studies. These programs used public health principles in combination with innovation to create health education programs designed to serve the unique needs of farmers. Program planners incorporated community partnerships in program development and implementation by identifying and recruiting the support and participation of community stakeholders. Nurses can use techniques similar to those in the reviewed studies (e.g., focus groups and epidemiologic studies) to supply useful information about potential program participants, their needs, and preferred methods of program delivery. Agricultural health and safety program planners are faced with the challenges of working with a population characterized by strong individualism among workers, geographic dispersion, and multiple independently owned enterprises. Innovative methods of delivering services to farm families are necessary to pro- 468 PRACTICE & RES EAR C H mote efficacy of health and safety interventions. Several studies (Marlenga, 1995; Outterson, not dated; Schwab, 1993) suggested that farmers often use farm magazines, newspapers, television, radio, and friends as sources of health information. Nurses working with agricultural workers, like program planners in the interventions described, may consider using nontraditional methods to deliver farm safety messages. Unlike many employees in the industrial sector, the occupational and environmental unit for the majority of American farms is the farm family. Program developers in the studies reviewed focused on the needs of farm families in their program assessment phase, and designed programs that would address the needs of the farm family. Health information was delivered to adults as well as youth, and safety messages were delivered directly to the farm where the entire farm family could benefit from it. Successful interventions are the product of collaborative efforts of broadly talented teams of researchers, professionals, local, state, and federal government agents, industry representatives, farm organization members, and community members. REFERENCES Ambe, E, Bruening, T., & Murphy, D. (1994). Tractor operators' perceptions of farm tractor safety issues and implications to agricultural and extension education. Journal of Agricultural Education, 35(4), 67-73. Centers for Disease Control and Prevention. (1993). Public health focus: Effectiveness of rollover protective structures for preventing injuries associated with agricultur- al tractors. Morbidity & Mortality Weekly Report, 42(3), 57-59. Connon, C.L., Freund, E., & Ehlers, J.K. (1993). The occupational health nurse in agricultural communities program: Identifying and preventing agriculturally related illnesses and injuries. AAOHN Journal, 41, 422-428. Etherton, J., Myers, M., Jensen, R., Russessl, J. & Braddee, R. (1991). Agricultural machine-related deaths. American Journal of Public Health, 81(6), 766-768. Kelsey, T., May, J., & Jenkins, P. (1996). Farm tractors, and the use of seat belts and rollover protective structures. American Journal of Industrial Medicine, 30, 447-451. Lehtola, C. (1993). A tractor injury intervention program. Presentation at the International Meeting of the American Society of Agricultural Engineers, Chicago, IL. Marlenga, B. (1995). The health beliefs and skin cancer prevention practices of Wisconsin dairy farmers. Oncology Nursing Forum, 22(4),681-686. Monroe, A., Ricketts, T., & Savitz, L. (1992). Cancer in rural versus urban populations: A review. Journal ofRural Health, 8, 212220. National Institute for Nursing Research. (1995). Community-based health care: Nursing strategies (NIH Publication No. 95-3917). Washington, D.C.: National Institutes of Health. National Safety Council (1997). Accident facts: 1997 Edition. Chicago: Author. Outterson, B. (not dated). Communicating pesticide safety to farmworkers: The radio pesticida project (agency report). Arlington, VA: Association of Farmworker Opportunity Prognfms, Reding, D., Krauska, M., Lappe, K, & Fischer, V. (1994). Cancer education interventions for rural populations. Cancer Practice, 2(5), 353-358. Schwab, c., & Miller, L. (1993). Evaluation of a farm safety and health communication campaign. In: Proceedings of the 1993 American Society of Agricultural Engineers International Winter Meeting, St. Joseph, MI. Reviewed by: Marjorie McCullagh, MS, RN, COHN-S AAOHNJOURNAL