A Human Rights-Based Approach to Farmworker Health: An Overarching Framework to Address the Social Determinants of Health

Retention of Agricultural Workers Participating in a Renal Longitudinal Study

OBJECTIVES

The relationship between heat stress, chronic kidney diseases and acute kidney injury has been documented in cross-sectional studies with agricultural workers. However, only a few international studies have assessed renal function in agricultural workers longitudinally. Our research study, Occupational Heat Exposure and Renal Dysfunction (OHEaRD) is the first longitudinal study in the U.S. that monitored renal function in agricultural workers five times over the course of 32-months. The main objectives of this study were to evaluate the rate of retention and identify predictors associated with retention in a longitudinal study with agricultural workers.

METHODS

In January 2020, we enrolled 119 Florida agricultural workers to observe on 5 workdays over 32 months. Retention was defined by the number of follow-up visits that a participant attended, the consistency of visit attendance, and attendance at the last visit. Participants were provided hemoglobin A1C, lipid panel, creatinine measurement, glomerular filtration rate (eGFR), blood pressure, and body mass index results and an incentive gift card were handed out to participants at each visit.

RESULTS

Four enrollees did not participate on any workday, thus analysis concentrated on the remaining 115 participants. The majority of participants (64%) completed the 32-month study, 78% completed at least 4 visits, and 55% completed all 5 visits. The statistically significant predictors of higher retention among this study were being older in age (p=0.02), Mexican nationality (p=0.004), working in ferneries (p=0.009), more years working in agriculture (p=0.02), and higher total cholesterol (p=0.02). Appreciation for the health tests was associated with greater participation at the final visit (p=0.01).

CONCLUSION

Retention in longitudinal studies is crucial to better understand kidney disease among agricultural workers, an understudied population. Participants reported valuing the access to health results, indicating that implementing point-of-care health screenings and providing the health results to each participant is a good retention strategy. There was some evidence that a participant living with or being related to a fellow co-participant could impact retention as they either showed up or missed visits together, suggesting recruiting from the same household may reduce retention.

The Influence of Organizational Aspects of the U.S. Agricultural Industry and Socioeconomic and Political Conditions on Farmworkers' COVID-19 Workplace Safety

Farmworkers in the U.S. experienced high rates of COVID-19 infection and mortality during the COVID-19 pandemic. Their workplace may have been a significant place of exposure to the novel coronavirus. Using political economy of health theory, this study sought to understand how organizational aspects of the agricultural industry and broader socioeconomic and political conditions shaped farmworkers' COVID-19 workplace safety during the pandemic. Between July 2020 and April 2021, we conducted and analyzed fourteen in-depth, semi-structured phone interviews with Latinx farmworkers in California. Findings show that regulatory oversight reinforced COVID-19 workplace safety. In the absence of regulatory oversight, the organization of the agricultural industry produced COVID-19 workplace risks for farmworkers; it normalized unsafe working conditions and the worker-rather than employer-responsibility for workplace safety. Under these conditions, farmworkers enacted personal COVID-19 preventative practices but were limited by financial hardships that were exacerbated by the precarious nature of agricultural employment and legal status exclusions from pandemic-related aid. Unsafe workplace conditions negatively impacted workplace camaraderie. Study findings have implications for farmworkers' individual and collective agency to achieve safe working conditions. Occupational safety interventions must address the organizational aspects that produce workplace health and safety inequities and disempower farmworkers in the workplace.

Provision of HIV prevention and care services to farmworkers in sub-Saharan African countries

OBJECTIVES

To summarise data on human immunodeficiency virus (HIV) services available to farmworkers in sub-Saharan Africa (SSA).

METHODS

We conducted a systematic review to understand which HIV prevention and care services were accessed by farm workers in SSA. MEDLINE (PubMed), Embase, CINAHL (EBSCO Host), Cochrane library, African Index Medicus, Scopus, Google Scholar, Open Grey, and Web of Science Proceedings Citation Index were searched. Studies were eligible for inclusion if they measured or reported on the presence of HIV workplace policy frameworks, guidelines, or programmes for HIV prevention, treatment and care services, and other treatment modalities specifically targeting farmworkers.

RESULTS

Nine studies published between 2005 and 2019 were included in the review. Six themes emerged from included studies, which include HIV policy, HIV prevention (awareness, education, and condom supply), voluntary counselling and testing, antiretroviral therapy (ART), linkage to care, and mobile clinic. Though availability of an HIV policy was inadequate, a significant positive impact of the HIV policy in influencing behaviour change was reported. Most of the farm workers could access HIV education and condom supply in their places of work. Access to ART, treatment support, and linkage to care was inadequate, but community outreach programmes and mobile clinics showed success in reaching a high number of workers with HIV testing and treatment. A majority of farm workers faced barriers in accessing government health facilities.

CONCLUSIONS

The findings suggest that there is poor access to HIV services for farmworkers in SSA. There is a dire need to scale up HIV services and programmes, including mobile health facilities, in agricultural settings. Due to high labour migration patterns among farmworkers, we recommend cross-country HIV programmes that allow continuity of care across borders.

Integrating NHANES and toxicity forecaster data to compare pesticide exposure and bioactivity by farmwork history and US citizenship

BACKGROUND

Farmworkers in the United States, especially migrant workers, face unique barriers to healthcare and have documented disparities in health outcomes. Exposure to pesticides, especially those persistent in the environment, may contribute to these health disparities.

OBJECTIVE

Quantify differences in pesticide exposure bioactivity by farmworker category and US citizenship status.

METHODS

We queried the National Health and Nutrition Examination Study (NHANES) from 1999-2014 for pesticide exposure biomarker concentrations among farmworkers and non-farmworkers by citizenship status. We combined this with toxicity assay data from the US Environmental Protection Agency's (EPA's) Toxicity Forecaster (ToxCast). We estimated adverse biological effects that occur across a range of human population-relevant pesticide doses.

RESULTS

In total, there were 844 people with any farmwork history and 23,592 non-farmworkers. Of 12 commonly detectable pesticide biomarkers in NHANES, 2,4-dichlorophenoxyacetic acid (OR = 3.76, p = 1.33 × 10-6) was significantly higher in farmworkers than non-farmworkers. Farmworkers were 1.15 times more likely to have a bioactive pesticide biomarker measurement in comparison to non-farmworkers (adjusted OR = 1.15, 95% CI: 0.87, 1.51). Non-U.S. citizens were 1.39 times more likely to have bioactive pesticide biomarker concentrations compared to people with U.S. citizenship (adjusted OR 1.39, 95% CI: 1.17, 1.64). Additionally, non-citizens were significantly more exposed to bioactive levels of β-hexachlorocyclohexane (BHC) (OR = 8.10, p = 1.33 × 10-6), p,p-DDE (OR = 2.60, p = 0.02), and p,p'-DDT (OR = 7.75, p = 0.01).

IMPACT STATEMENT

Farmworkers are a vulnerable population due to social determinants of health and occupational exposures. Here, we integrate US population chemical biomonitoring data and toxicity outcome data to assess pesticide exposure by farmwork history and citizenship. We find that farmworkers and those without US citizenship are significantly more likely to be exposed to concentrations of pesticides which are bioactive in toxicological assays. Thus, farmworkers employed in the US but who are not citizens could be at increased risk of harm to their health due to pesticides. These findings are important to shape evidence-based policies in regulatory science to promote worker safety.

Determining Regional Differences in Barriers to Accessing Health Care Among Farmworkers Using the National Agricultural Workers Survey

Farmworkers are an essential workforce in the U.S. We assessed the regions in the National Agricultural Workers Survey on the difficulty of accessing health care among farmworkers in the U.S. The study included 9577 farmworkers. Farmworkers in all regions were more likely to report having difficulty accessing health care because it was too expensive. The overall odds ratio for difficulty accessing health care was lower in the MW after adjusting. Farmworkers employed in the SE had greater difficulty accessing health care because of language barriers. Farmworkers employed in CA had difficulty accessing health care in the U.S. because it was too expensive or far away. Results follow previous studies on barriers to access health care among the farmworker population. Understanding regional disparities in the presence of barriers to accessing health care among farmworkers is an essential step to improving equitable health care access in the U.S.

CDC-Supported National Network of Farmworker-Serving Organizations to Mitigate COVID-19

The Centers for Disease Control and Prevention has partnered with the National Center for Farmworker Health to respond to the impact of COVID-19 on US farmworker communities. Immigrant farmworkers are often isolated from public health infrastructure. This partnership built the capacity of a national network of organizations to connect farmworkers to COVID-19 education and vaccinations in 20 states through training and resource sharing. The partnership funded 194 network member staff, trained 1130 individuals, and supported COVID-19 outreach to more than 600 000 farmworkers. (Am J Public Health. 2023;113(2):166-169. https://doi.org/10.2105/AJPH.2022.307159).

Integrating NHANES and Toxicity Forecaster Data to Compare Pesticide Exposure and Bioactivity by Farmwork History and US Citizenship

Introduction

Farmworkers in the United States, especially migrant workers, face unique barriers to healthcare and have documented disparities in health outcomes. Exposure to pesticides, especially those persistent in the environment, may contribute to these health disparities.

Methods

We queried the National Health and Nutrition Examination Study (NHANES) from 1999-2014 for pesticide exposure biomarker concentrations among farmworkers and non-farmworkers by citizenship status. We combined this with toxicity assay data from the US Environmental Protection Agency's (EPA's) Toxicity Forecast Dashboard (ToxCast). We estimated adverse biological effects that occur across a range of human population-relevant pesticide doses.

Results

In total, there were 1,137 people with any farmwork history and 20,205 non-farmworkers. Of the 14 commonly detectable pesticide biomarkers in NHANES, 2,4-dichlorophenol (OR= 4.32, p= 2.01×10 -7 ) was significantly higher in farmworkers than non-farmworkers. Farmworkers were 1.37 times more likely to have a bioactive pesticide biomarker measurement in comparison to non-farmworkers (adjusted OR=1.37, 95% CI: 1.10, 1.71). Within farmworkers only, those without U.S. citizenships were 1.31 times more likely to have bioactive pesticide biomarker concentrations compared those with U.S. citizenship (adjusted OR 1.31, 95% CI: 0.75, 2.30). Additionally, non-citizen farmworkers were significantly more exposed to bioactive levels of β -hexachlorocyclohexane (BHC) (OR= 8.50, p= 1.23×10 -9 ), p,p-DDE (OR= 2.98, p= 3.11×10 -3 ), and p,p'-DDT (OR= 10.78, p= 8.70×10 -4 ).

Discussion

These results highlight pesticide exposure disparities in farmworkers, particularly those without U.S. citizenship. Many of these exposures are occurring at doses which are bioactive in toxicological assays.

The TN Visa: The Future of Foreign Workers in Livestock Production

Agricultural employers have faced extreme challenges in recruiting and retaining an adequate workforce. Various societal changes have made hiring local workers into agricultural jobs difficult. Therefore, there is a growing reliance on foreign workers and visa programs to meet labor demands. One such program, the TN visa, can be an effective and useful tool for recruiting professional labor for livestock operations, and many agricultural employers have already seen its value. It is likely that the use of the TN program will continue to grow in the future. However, there is opportunity for misuse and abuse of the TN program because there are few administrative rules and limited oversight. We offer recommendations to improve the TN program and the well-being of TN professionals including additional oversight of the program, transparency in recruiting and contracting workers, educating TN workers about U.S. labor rights, ensuring fair pay, and allowing a path to work authorization for TN workers' spouses and children who accompany them in the U.S. Clearly, sustainable solutions to the farm labor shortage are needed. As a field, we need to better understand workforce recruitment and retention concerns as well as mechanisms being used to address such concerns and their impact on workers' health, safety, and well-being.

Colorado Agricultural Workers' Rights of Access to Key Healthcare Providers: A Policy Brief

Health is a human right. In order to exercise their right to health, agricultural workers need to have access to medical, dental, and behavioral health care. Agricultural workers need to have medical, dental, and behavioral health care available at times and locations that are amenable to their work schedules and worksites. Many agricultural workers do not have access to transportation due to the nature of their working conditions, therefore policies to provide transportation will increase access to medical, dental, and behavioral health services.

Global Is Local: Interprofessional Experiential Learning for Migrant Farmworker Health Equity

Purpose

Medical educators recognize the importance of addressing social determinants of health and providing opportunities for learners to work with diverse populations. Still, social, geographic, resource, and language barriers prevent institutions from connecting with globally diverse populations within their own communities. In this article, we describe the migrant farmworker health course at the University of Minnesota, the importance of longitudinal partnership with community-based organizations, and ways to increase access to care and educate health professional learners in health equity.

Methods

The migrant farmworker health course is a clinical rotation that combines didactic learning on social determinants of health with hands-on clinical experience. Learners work with community organizations to provide mobile health care while learning about a diverse and underserved rural population. Twenty-eight learners who participated in the course between 2015 and 2019 were surveyed about their experience, knowledge, and skills gained, and recommendations for improvement.

Results

Over 90% of participants rated their overall experience in the course as “good” or “outstanding.” Most learners increased confidence in the subjects that were covered during didactic sessions. Qualitative feedback provided insight on how the migrant farmworker health course shaped learners' understanding of social determinants of health and influenced their career trajectories.

Conclusion

The migrant farmworker health course has educated interprofessional learners and is expanding to include more opportunities for mobile health care. The feedback from this survey helped improve didactic teaching and will help deepen relationships with community partners. Learning through service with global populations locally in a “global is local” rotation is a rewarding way to engage in and learn about health equity.

Innovative Cohort Process to Minimize COVID-19 Infection for Migrant Farmworkers During Travel to Iowa

Background: Migrant and seasonal farmworkers (MSFW) experience disproportionate infection, severe disease and death from COVID-19. This report describes an innovative process to address the safety of MSFW that utilized cohorting that eventually allowed for safe release to work in the fields on a large family farm in Iowa. Methods: Upon worker departure from Mexico, the employer arranged for bus seat assignments, mask use, and hand hygiene practice during the 3-day trip to Iowa. Upon arrival at the farm, surveillance testing and low-density housing cohorting based upon travel seat assignments allowed for early identification of infected workers and appropriate quarantine as per CDC guidelines. Upon completion of isolation or quarantine as appropriate, workers were released to congregate housing and work in the fields. Findings: Compared to a migrant farmworker COVID-19 outbreak without travel pre-planning, the cohorting process produced a 3.5% positivity rate compared to an earlier season July farmworker group on the same farm with a 12.7% positivity rate. Conclusions/Application to Practice: The success of this model points to the power of collaboration between farm employer, health care providers and workers to minimize worker infection and enable safe work in the fields. Increased state and federal support for MSFW protections could support infrastructure to proactively plan for prevention mechanisms to prevent the spread of known communicable disease. With support in place from the top down, employers, workers, and health care providers will be able to prioritize the management of infectious diseases and the needs of essential workers.

Barriers to Access for Cervical and Breast Cancer Screenings Among Female Latinx Migrant Farmworkers in the US: A Scoping Literature Review

Identification of barriers to cancer screening among female migrant farmworkers is needed to inform intervention development and healthcare policy. Thus, our purpose was to systematically review and summarize findings from prior studies of barriers faced by Latinx migrant farmworkers in accessing cervical and breast cancer screenings in the US. Medline and Embase were used to identify literature through October 2021 using the search terms “migrant farmworkers AND. . .cancer; healthcare access; breast; cervical; federally qualified health centers,” and “migrant cancer screening” and “migrant farmworker cancer screening.” Snowball sampling by reviewing citations in each selected article was also used. Exclusion criteria included those articles that focused on specific types of cancer other than breast or cervical, those not within the US, not referencing Latinx migrants, not referencing cancer screening, or those focused on pediatric populations. Data was synthesized by 3 authors and selected articles were assessed for common themes. Nineteen articles met inclusion criteria. Common themes about barriers to cancer screening included: lack of cancer knowledge, cost/inability to pay, lack of health insurance coverage, cultural perceptions, fear, language difficulties, and transportation and time constraints. Findings suggest that barriers to cancer screening among migrant farmworkers may be addressed by providing education about cancer screening and treatment, addressing fear, language, and cultural barriers, and providing transportation and health insurance coverage. Consideration of these barriers is necessary to effectively address cancer disparities in this vulnerable population of female farmworkers.

Occupational Injuries among Latino/a Immigrant Cattle Feedyard Workers in the Central States Region of the United States

Agriculture is a dangerous industry with high rates of occupational injuries. Immigrants comprise the majority of the hired agricultural workforce in the United States, and these workers may be at a higher risk for job-related injuries. This study addressed the frequency, characteristics, and risk factors of occupational injuries among Latino immigrant cattle feedyard workers. Data were collected through structured interviews with Latino immigrant cattle feedyard workers in Kansas and Nebraska (n = 243; 90.9% male). Descriptive statistics and logistic regression were used to identify risk factors for injury. Nearly three-fourths of participants (71.2%) reported having experienced one or more injuries in the past while working on a cattle feedyard. The most frequent types of reported injuries, including those not requiring medical care, were bruises/contusions (40%), cuts/lacerations (21%), and sprains/strains (12%). These injuries were mainly caused by animals/livestock (33%), chemicals (23%), falls (12%), and tools (9%). Significant risk factors for injury included male gender (OR 5.9), being over age 35 (OR 2.6), working on a large or an extra-large feedyard (OR 5.4), having 11 or more employees on the feedyard (OR 3.6), and working more than eight hours a day (OR 4.7). Having received safety training was also associated with greater risk of injury in a univariable model (OR 2.6). Cattle feedyard workers are at high risk for injury and require more effective preventive measures.

Heat Stress and Kidney Function in Farmworkers in the US: A Scoping Review

Chronic kidney disease of unknown etiology (CKDu) has been well described in farmworkers in Latin America. Agricultural workers in the United States (US) are exposed to similar hot and humid working conditions, but CKDu in the US is under-described. This review aims to better understand the current literature describing the connection between heat stress and kidney function in farmworkers in the United States. Utilizing a scoping review methodology, we searched CINAHL, Embase, PubMed, and Web of Science databases to better understand the current state of the heat stress and kidney function research in farmworkers within the United States. In this review, 229 pieces of literature were screened. Ultimately, 4 articles were chosen to be included in the scoping review. Common themes within the articles were variations in study protocol lengths and type of heat stress measurement. Additionally, the majority of the work completed was quantitative to date, with only one study providing a critical social lens for analysis of CKDu in the United States. We found evidence that more work is needed within the US to understand the relationship between working in the heat and kidney function in agricultural and other workers who experience high heat conditions at work and are susceptible to the deleterious effects of working in said conditions.

Analyzing the predictors of health care utilization in the agricultural worker population using decision tree analysis: Does language matter?

OBJECTIVES

To analyze the predictors of health care utilization among respondents to the National Agricultural Worker Survey. Specifically, we hypothesized that English proficiency would predict utilization of health care services within the last 2 years.

METHODS

Using the 2015-2016 National Agricultural Worker Survey, we performed a secondary data analysis to analyze the predictors of health care utilization within the last 2 years in the United States' agricultural worker population. Data were cleaned and analyzed using decision tree analysis, which produced a classification tree model that was trained on 90% of the data and validated on 10%.

RESULTS

Exposure to English was not a predictor of health care utilization in our classification tree. The first major partition that predicted utilization was insurance status. Additional partitions were on age, gender, hypertension diagnosis, and public aid.

CONCLUSIONS

By partitioning on insurance status and use of public aid, the decision tree provided evidence that systemic factors are key determinants of health care utilization in the agricultural worker community. This highlights the importance of agencies that connect agricultural workers with resources that provide insurance and improve access to health care. This is especially important given that agricultural workers are one of the highest risk groups for occupational injury or death in the United States.

Virtual Outreach: Using Social Media to Reach Spanish-speaking Agricultural Workers during the COVID-19 Pandemic

Face-to-face outreach and in-person training have traditionally been key strategies in reaching agricultural producers, workers, and communities with safety and health information, but the COVID-19 pandemic has forced outreach educators to be creative and find alternative ways to reach, communicate, and share such information. In this commentary, we describe our use of social media to reach Latino/a cattle feedyard workers with COVID-19 related information. As a result of our effort, we reached over 54,000 people and demonstrated there is an audience for Spanish-language agricultural safety and health information. Social media can be a cost-effective method for virtual outreach in this new normal. We should look at this time as an opportunity to learn more about how our stakeholders obtain information and about how best we can connect with them. Although our outreach methods may be changing, our goal is not - we will continue to work to improve the safety and health of those who work in agriculture.

"If We Don't Produce, Bring Another:" Work Organization and Tomato Worker Health

Objectives: Specific work processes and management structures that contribute to high rates of occupational illness and injury in agricultural industries are not well described in academic literature. This qualitative study of work organization in the U.S. fresh tomato industry investigates how work processes and management structures impact tomato workers' occupational health. Methods: After conducting literature review and key informant interviews, semi-structured interviews and focus groups were conducted with 36 individuals with experience working in the U.S. fresh tomato industry. Interviews and focus groups were audio-recorded, transcribed, coded, and analyzed using a modified grounded theory approach. Results: These data indicate that participants endured income insecurity and hazardous supervisory practices, including wage theft, retaliation, intimidation, and humiliation, that put them at risk of preventable illness and injury. Support from workers' organizations and health-conscious supervisory practices helped mitigate some of these occupational hazards. Conclusion: Participants' adverse work experiences may be considered sequelae of workers' lack of job control and positions of socioeconomic structural vulnerability. Other aspects of tomato work organization, including health-conscious supervisory practices and the involvement of workers' organizations, indicate that modifying work organization to better safeguard health is possible. Such modifications present compelling opportunities for employers, employees, organizations, community and government leaders, and health care professionals to help create healthier occupational environments for tomato workers.

A Preliminary Analysis of Immigrant Cattle Feedyard Worker Perspectives on Job-Related Safety Training

Immigrants comprise a large percentage of the agricultural labor force in the United States. They are a vulnerable worker population and often have fewer occupational and social protections. Latino immigrant cattle feedyard workers (N = 68; 59 men; mean age = 38.7 years) in the central Midwest reported on their perceptions and preferences for job-related safety training and practices. Preliminary findings indicate that approximately 40% of workers reported that they had not received any health or safety training from their current employer, and only about 13% had ever participated in any Occupational Safety and Health Administration (OSHA) safety training program. In-person training, videos, or shadowing another worker were the most frequent methods of safety training reported by those who had received training. More than 90% were interested in receiving more information about health and safety related to their job. Workers preferred that safety information be provided through in-person training at the job site, videos (particularly those accessible through media sources such as YouTube), and written materials. Specific topics that workers were interested in obtaining more information about included zoonoses, low-stress cattle handling, injury prevention, hazard and injury reporting, chemical and equipment safety, and teamwork. Furthermore, a majority of participants preferred to receive information in Spanish. Results may help guide the development of future materials and training strategies to better suit the needs of the growing immigrant workforce in production agriculture.

Self-Reported Occupational Injuries and Perceived Occupational Health Problems among Latino Immigrant Swine Confinement Workers in Missouri

Swine production has changed dramatically, and in the United States production often takes place in concentrated animal feeding operations (CAFOs). Because of the size and density of these types of facilities, workers may be exposed to serious occupational health risks such as noxious gases, agricultural dusts, elevated noise levels, and zoonotic diseases. This descriptive study examines self-reported occupational injuries and perceived occupational health problems among a convenience sample of 40 Latino immigrant swine confinement workers (92.5% male; M age = 36.1 years; SD = 10.0) in Missouri. Results indicated that seventeen workers (42.5%) rated their health as fair or poor, thirteen (32.5%) had experienced an occupational injury, and eleven (28.2%) reported occupational health problems such as burning eyes, muscular pain, headaches, coughing, nausea, nasal congestion, and sneezing. The majority of workers did not perceive their job to be dangerous. Clearly, more must be done to protect workers, especially immigrant workers, who may not have the same access to information, training, or other protections. Health and safety should be a priority for both farmworkers and farm employers. Practical and policy-based implications and recommendations are discussed.