Abstract
Unsafe use of hazardous pesticides is a neglected public health problem in developing countries. This survey evaluates the effects of a training program to increase awareness on harmful effects of pesticides and to enhance capacity for safe handling involving 57 trained farmers, 98 neighboring farmers, 94 control farmers, and 23 pesticide retailers from villages in Chitwan, Nepal. Knowledge and attitude–related variables improved in all 3 farmer groups, with a significant trend of better knowledge and attitude from trained to neighboring to control farmers (in 14/16 [87.5%] variables). In practice, there were significant differences among the groups with a trend from trained to neighboring to control farmers (in 10/26 [38.5%] variables).The pesticide retailers also improved on knowledge and practice. In conclusion, training farmers and pesticide retailers improved their knowledge and practice, with possible positive effect on neighboring farmers and control villages as well. An improved extension service to farmers is recommended.
Introduction
Pesticides form an important part in increasing agricultural production. 1 However, their ingredients have been shown to induce acute toxic effects in practice and in different experimental systems. 2 Exposure to chemical pesticides is one of the most significant occupational risks among farmers in the developing countries 3 as they can easily get in contact with the pesticides, for example, when mixing the chemicals or when applying them to the crops and when pesticide residues are carried home. 4 Use of pesticides is linked to long-term and short-term health effects such as headache, dizziness, skin irritation, and blurred vision among small-scale farmers. 5 Although pesticide poisoning is a global issue, 6 developing countries 7 are affected relatively more than the developed countries. 8
Pesticide is a complex issue globally, and Nepal is no exception, 9 particularly in terms of the challenges that it brings. 10 Although its exact health impact among Nepalese population is not known due to lack of awareness among health workers and a good reporting system, studies have shown that farmers exposed to pesticides have a lower erythrocyte acetyl cholinesterase level, 11 often at a subclinical level. 12 Nepal, a developing country in South Asia, is an agro-based country where more than 173 common types of insecticides, 62 types of fungicides, and 24 different brands of herbicides are being used. 13 Over the years, with the introduction of high-yielding varieties and expansion of areas for the cultivation of rice, maize, wheat, and vegetables, Nepal has experienced an increasing tendency to use pesticides, by about 10% to 20% per year. 14 Furthermore, the increasing trend of pesticide use in market-oriented vegetables and fruit production in Nepal has been a major cost factor. 15
As elsewhere, Nepali farmers also confront a particularly high risk of pesticide poisoning due to the added risk from their occupational exposure through pesticide management when mixing, applying, spraying, transporting, storing, taking care of equipment, reentering into the field, spillage, and doing careless disposal. 9 Poor knowledge and practice among farmers and retailers on proper protection, safe storage, and spraying interval before harvest leads to increased risk of pesticide poisoning.16,17 Although this is true in case of Nepal too,12,18 the problem is further accentuated by inadequacy of information or education on pesticide toxicity in its health and agriculture services system. 11 Although Integrated Pest Management (IPM) has been a major program of the government for 2 decades to mitigate irrational and overuse of chemical pesticides,19,20 with Farmer Field School (FFS) training as the main strategy,9,15,19,20 this is a first attempt at community level to integrate the health dimension into the intervention. Indeed, from an economic point of view too, 21 bringing health in the front as the primary motivation for bringing change can be a successful intervention strategy. 22
Therefore, with the aim of promoting health of farmers and consumers by promoting healthy and sustainable food production, Nepal Public Health Foundation implemented “Farming, Health and Environment Nepal 2013/15 Project (FHEN)” in the Chitwan District of Nepal in April, 2013. This project was designed as a multisectoral approach to address the negative influence of pesticides on public health and the environment due to occupational and environmental exposure. Specifically, the project aimed to increase awareness among farmers and pesticide retailers about harm due to exposure to pesticides and enhance their capacity for safe handling of pesticides. This article describes the impacts of the project interventions by assessing changes in knowledge, attitude, and practice on proper use of pesticides and alternatives among the farmers and retailers by comparing data collected at project start and end.
Materials and Methods
Study design
This is a descriptive survey, comparing 2 cross-sectional studies conducted at project start and project end in Chitwan, an inner Terai district in the Central Development Region of Nepal. The study period covers 3 years from 2013 to 2015.
Study site, population, and sample
The Chitwan District is 1 of the 75 districts and is situated in Southern Nepal (Figure 1). In total, 5 villages of Chitwan were purposively selected as intervention sites (project villages) and another 5 as control (nonproject) villages (Figure 2) on recommendation of the local stakeholders. At least 1 farmer who had been actively working for at least 2 years as a farmer was selected from each intervention village to go for project training.
Map of Nepal showing the location of Chitwan District (shown in red).
Map of Chitwan District showing project and control villages.
From the project villages, 60 farmers going for training were selected by the Farmers’ Cooperatives and participated in the trainings and other activities conducted by the project (key farmers). A total of 100 neighboring farmers to whom knowledge and skill were assumed to be transferred by the trained farmers were selected by convenience when found at home (fellow farmers), and 100 control farmers, who did not receive any project interventions, were selected the same way from neighboring villages.
Administratively, all villages were divided into 9 wards and samples were taken proportionately based on household population size from all wards. Only 1 person who was mostly involved in agriculture activities from each household was taken as respondent. The same farmers who were interviewed in the baseline were intended to be interviewed in the follow-up, as far as possible. We ended up with 57 trained farmers, 98 neighboring farmers, and 94 control farmers who had a data set suitable for further analysis. A total of 23 pesticide retailers in the project villages and of the nearby market areas from where farmers of project villages usually purchase pesticides also received trainings and were included in the baseline and the follow-up surveys.
Intervention
The key farmers took part in FFS organized specifically for the purpose which provided 10 to 15 theoretical and practical courses about IPM, health, and environment. The project then supported the trained key farmers in passing their acquired knowledge on to their neighboring fellow farmers acting as a kind of local consultant on pesticide matters in their villages.
The pesticide retailers were trained and they later participated in the education of the farmers in their pesticide shops to strengthen their knowledge of pesticide use and its safe handling, making them able to continuously supervise and educate the farmers’ groups in the district. This information from the retailers might have reached the control group as well.
Data collection and variables
Face-to-face interviews in Nepali language were conducted with farmers and pesticide retailers using a structured questionnaire. In addition, direct observation method using observation checklist was applied to collect supplementary information in the household and pesticide retailers’ survey. Questionnaires were adopted from validated standard tools applied in similar surveys from Uganda and Bolivia.5,17 Questionnaires were translated into local Nepali language and modified into Nepali context. Questionnaires and observation checklists were pretested in a similar field setting before use in the actual survey. The farmers also reported whether they had any acute symptoms during handling and spraying of pesticides, such as headache, dizziness, dryness of mouth, muscle cramps, backache, etc.
Data management and analysis
The entire data set collected during the household survey was cleaned, coded, and entered into and analyzed with SPSS software version 22 (IBM, Armonk, NY, USA). Descriptive statistics such as mean and standard deviation were calculated for the continuous variables, and percentage distribution according to different characteristics of respondents was calculated for the categorical variables. The χ2 test was applied for assessing differences in proportions for various variables among the 3 categories of farmers in the baseline and endline surveys.
Knowledge and attitude on pesticides and pest control among farmers was summarized in an aggregated variable comprising 16 variables. The variables are the ones presented in Table 2. For each positive response, a value of 1 was assigned, and for each negative response, a value of 0 was assigned. The total score was the summation of scores obtained in the 16 variables. Similarly, to measure the change in the level of the safety practices, an aggregate variable was developed using the 26 practice-related variables shown in Table 3.
We applied 1-way analysis of variance (ANOVA) to compare the aggregated scores across the 3 categories of farmers, at baseline and at endline. To control for possible confounders, we dichotomized the aggregated variables on knowledge/attitude and on practice and performed a logistic regression analysis. For both knowledge/attitude and safe practice aggregated variables, scores below the median values were considered as “low score” and were coded 1, and those equal to or higher were taken as “high scores” and coded 2.
Ethical considerations
The project received ethical approval from Nepal Health Research Council (NHRC) at the time of its implementation (NHRC approval number: 113/2013). We obtained verbal consent from the study participants. The enumerators maintained confidentiality during the interviews. There was no possible harm to the participants because of the intervention or the surveys.
Results
The sociodemographic characteristics of the farmers who participated in the study are presented in Table 1. Significant differences were observed between the 3 categories of farmers for sex, area of arable land held, whether the farmers were members of any cooperative, and whether they had previously been trained in safer pesticide use or not. Mean age of all farmers was 41.8 (SD: 10.6) years with no significant difference between the 3 farmer groups regarding age.
Sociodemographic characteristics of the farmers (Pearson χ2 test).
1 katha = 339 m2.
Impact on knowledge and attitude of the farmers
Table 2 shows farmers’ knowledge and attitude on various aspects of pesticide use, at baseline and at the endline survey. At baseline, the key farmers selected for trainings had better knowledge than their neighbors, whereas the latter had better knowledge than the controls on most variables. In 9 of the 16 variables, a significant trend was seen in a linear-by-linear analysis. After training, there was an improvement in most of the variables among all 3 groups of farmers with many of them being significant. A significant trend was now seen in 14 of the 16 variables in a linear-by-linear analysis. Figure 3 presenting an ANOVA analysis on the aggregated variable on knowledge and attitude shows a significant increase in score within all farmers’ groups at the endline compared with their baseline. There was also a significant difference between all 3 groups at endline, which was not the case between the trained and neighboring farmers at baseline.
Knowledge and attitude on pesticide use and alternatives among farmers seen in 16 variables compared at baseline and endline (Pearson χ2 test and linear-by-linear association, significant positive differences marked with gray).
Abbreviations: IPM, Integrated Pest Management; PPE, personal protective equipment.
Aggregated knowledge and attitude scores among the 3 farmer groups, at baseline and endline (maximum score of 16; 1-way analysis of variance). CI indicates confidence interval.
Impact on practices of the farmers
For most of the practice-related variables, positive changes were noted within all 3 categories of farmers with many of them being significant (Table 3). At baseline, the key farmers selected for trainings had better practice of handling pesticides as shown by higher proportion on better practice in most of the variables. There was a decreasing trend of these proportions from key farmers to neighboring to control farmers, and the differences were significant for 5 of the 26 variables as seen from a linear-by-linear analysis. At endline, the picture was the same but with 10 significant differences. Figure 4 presents an ANOVA analysis on the aggregated variable on practice. It shows a significant improvement within all 3 groups from baseline to endline. Although no significant difference was seen between the 3 groups at baseline, a significant difference was seen at endline.
Practice when handling pesticides and alternatives among farmers seen in 26 variables compared at baseline and endline (Pearson χ2 test and linear-by-linear association, significant positive differences marked with gray, significant negative differences marked with red).
Aggregated practice score among the 3 farmer groups, at baseline and endline variable (maximum score of 26; 1-way ANOVA). CI indicates confidence interval.
In the controlled analysis, odds ratios were calculated for a score higher than median score in the aggregated variables for knowledge and attitude (Table 4). We saw that odds ratios were higher both at baseline and endline among trained farmers compared with the other 2 groups, although this difference in odds ratios was smaller at endline. In the practice variables, we saw a noticeable improvement in odds ratios from baseline to endline among both the trained and the neighboring farmers compared with the control farmers.
Odds ratios for a high score in the aggregated variables on knowledge and practice among the 3 farmer groups at baseline and at endline (logistic regression analysis controlled for age, sex, education, and size of arable land).
Abbreviation: CI, confidence interval.
Impact on health of the farmers
The proportions of trained key farmers and fellow farmers reporting acute symptoms of pesticide poisoning immediately after spraying decreased from 51.7% to 30.8% (P = .035) and from 49.5% to 33.3% (P = .023), respectively. In comparison, the control farmers increased the number of symptoms from 31.3% to 37.0% (P = .447). Headache (20.9%), dizziness (12%), dryness of mouth (8.9%), muscle cramps (6.6%), backache (5.7%), and lethargy (5.7%) were the most commonly reported symptoms, followed by breathing difficulty (4.4%), difficulty in speaking (3.2%), abdominal pain (3.2%), and perspiration (2.5%).
Impact on perceptions and practices of the pesticide retailers
Of the 23 pesticide retailers, most of them were men (82.6%), aged ⩾30 years (73.9%) (mean age ± SD = 38.1 ± 11.8, range: 22-61 years), and education at least up to higher secondary level (60.6%). Three-fourths (78.3%) of the retailers were license-holding shop owners. Others (21.7%) were not license holders themselves but were staffs or relatives. Most of the retailers sold pesticides along with veterinary medicines (69.6%) or general goods (21.7%). In all, 21 had previously received training on pesticides.
Five variables related to knowledge on pesticides were assessed, and all were improved as shown in Table 5. Although the baseline survey revealed that 58.33% of the pesticide retailers were selling unregistered pesticides to the farmers, the endline survey found that none were selling them (P < .001) (Table 6).
Knowledge of pesticide dealers on pesticides.
Pesticide handling by pesticide retailers before and after intervention.
Abbreviation: PPE, personal protective equipment.
Improvements were also found in counseling of farmers and in the sale of personal protective equipment (PPE), botanical pesticides, insect pheromones/attractants, and unregistered pesticides. However, there were reductions in the proportion of safe practices such as the use of PPE and selling of organic pesticides. Nonetheless, the endline result showed that there were improvements in common hygienic practices among pesticide retailers, although the changes were not statistically significant.
Discussion
The survey revealed a significant increase in the knowledge and practice level of pesticide handling and alternatives to pesticides in each of the 3 farmer groups from baseline to endline. Trained farmers performed better than neighboring farmers, who in turn performed better than the control farmers both at baseline and endline on knowledge and attitude parameters. The same was seen for practice showing significant differences at endline among the 3 groups which was not the case at baseline. Less incidences of pesticide-related health symptoms were also noted among the trained and fellow farmers. The fact that the trained farmers improve in their knowledge and pesticide handling practice has been consistently shown in various studies.23-33
By training a group of farmers through FFS, we expected “dissemination of knowledge” into their neighboring farmers as well. Indeed, past studies report mixed outcomes regarding dissemination with many of them conveying possible dissemination,34-37 whereas others did not find any significant dissemination.25,27,32,33,38 Our follow-up study saw improvements in knowledge of neighboring farmers similar to the trained farmers, but less change was noted when it came to the improvement of their practice. It is our experience that the major facilitators for dissemination from trained to neighboring farmers included personal qualities such as leadership quality and enthusiasm of the trained farmers. Factors that diminished transfer of knowledge were mostly related to neighboring farmers, eg, seeking financial benefit from the project, disinterest toward learning, not receiving PPE as the trained farmers did, difference in socioeconomic status from the trained farmers. Factors related to the trained farmers, such as lack of enthusiasm and inadequate teaching skills as witnessed by the project staff during their monitoring visits, also affected effective dissemination. In fact, such barriers in transferring farmer-to-farmer knowledge have been discussed in other similar settings such as in Indonesia, 33 Vietnam, 39 Zimbabwe, 31 and various African countries. 40
Because our study was done within a development project rather than a research project, it had some shortcomings from a research perspective, an issue already well recognized. 41 Unlike in a well-randomized trial, the 3 categories of farmers in our study were dissimilar right from the beginning in various aspects. For example, there was more gender equality among the trained farmers because the project had urged the villagers to balance the genders going for the training courses. Likewise, the difference in landholding was expected because those who are selected for such voluntary courses are often better off, people have more trust in them, and they have a certain respect in the society. Unlike the control farmers, almost all the trained farmers and their neighboring farmers were members of cooperatives because they were accessed through the farming cooperatives. Such dissimilarities among the different groups of farmers have been reported in other studies as well.24,25,27,33
The background differences in the farmers are reflected in the baseline knowledge and attitude assessment as well. As a higher proportion of the trained key farmers and neighboring farmers belonged to a cooperative and had already received some training on pesticide use, they had better knowledge on more variables than the control farmers. One of the advantages of belonging to a cooperative as mentioned by the farmers is the support on equipment and training they get. Another explanation is that when the farmers among themselves choose a person to go for trainings, they often choose the better educated farmers, as seen in other surveys.5,14 Furthermore, there was greater improvement in knowledge and attitude among the trained farmers, which can be attributed to the training. Higher improvement among the control farmers than neighboring farmers could be due to the lower knowledge level from the outset with more room for improvement in this group of farmers, as observed in other studies as well.27,42
Regarding safety practices, improvement was noted in all 3 categories of farmers. The reason for most improvement in the trained group is probably the training, and knowledge could have been passed on to the neighboring farmers as they improved the second most. The improvement among the control group could be due to 2 reasons. First, it is likely that knowledge had been disseminated from the project, as the control villages were not far away from the intervention villages.26,43 Second, a general raise of knowledge level is likely to be occurring among the farmers as Chitwan has been receiving IPM training by government 44 and other nongovernmental agencies. 45 Also, several district-wide campaigns on safer pesticide use and alternatives were conducted during the project period. In addition, most farmers, irrespective of whether the farmers belonged to intervention or control villages, get their advice from the pesticide dealers many of whom were trained by the project to provide proper advice to them. Hence, influence on both intervention and control villages from other IPM activities cannot be ruled out. But as the effect of such external influence would be more or less equal in both intervention and control villages, the additional improvement in pesticide knowledge and practice among the trained farmers can probably be well credited to our intervention.
Besides the farmers, our intervention led to an increased level of knowledge among the pesticide retailers improving their knowledge about banned pesticides, color codes used in pesticide containers, toxicity levels of different pesticides, and their adverse health effects. Another important impact of the intervention was that unlike in the baseline, none of the retailers were selling unregistered pesticides at follow-up. They had better hygienic and counseling practices and improved their sale of PPE. Many of the changes were not significant, though, probably due only to their small number. Especially, in the low-income country settings, many pesticide retailers have low knowledge of pesticides 46 and are prone to professional misconducts, 47 and more importantly, they are often a major source of information for the farmers. 48 Indeed, pesticide retailers themselves are at a higher risk of pesticide toxicity.16,49 Hence, enhancing their perceptions and practice through such trainings can indeed be valuable adjunct to rational use of pesticide in farming. 50 Intervening retailers along with the farmers have been shown to be effective in other settings as well. 51
There were convincing grounds for us to purposively select the Chitwan District of the 75 districts of Nepal for our project. There is intensive vegetable cultivation and also because pesticide use in widely prevalent. Chitwan was largely an uncultivated dense forest before the Nepal government started spraying DDT for the Malaria Eradication Project in 1950s.52-54 Immediately after control of malaria, Chitwan became a major farming region, and services and infrastructure expanded across the area. 55 Agriculture has been the primary source of income for 75% of the population in the district. Of the total 46 894 hectares of arable land, 44 291 hectares is used for agricultural purpose, of which about 6300 hectares is used for commercial vegetable production. 55 It is one of the highest vegetable growing districts of Nepal. 56 According to the District Agriculture Office, there are 4000 to 5000 persons actively working as commercial vegetable farmers. 55 Thus, Chitwan was probably the best site for implementing our intervention project.
Nonetheless, our project had several limitations. Because of various logistic problems, not all the participants in the baseline could be interviewed in the follow-up and we had to interview another agro-active member of the same family if they were available and willing to participate. Such loss to follow-up is common in community interventions of long durations as the participants change profession, migrate, or die. Follow-up is particularly difficult in developing countries because of a weak civil registry and difficulties in reaching the households.22,57
Apart from the unintentional selection bias of the farmers mentioned earlier, the villages also were not randomly selected. Low sample size, particularly of the pesticide retailers, may also have affected interpretation of our findings. Furthermore, possibility of recall bias while recalling symptoms cannot be ruled out as the trained farmers were more likely to recognize and remember any symptom related to pesticide poisoning than those who were not trained. 22 Thus, considering sample size and sampling, and possible biases, the results of the study have to be taken cautiously. In addition, although there was intention of influencing positive policy changes, the project could not effectively achieve this important goal. Indeed, to yield larger countrywide benefits, multipronged approached that incorporated policy changes would definitely have been desirable. 58 Also, we did not explore gender perspectives on pesticides in our study, which can be an important dimension especially to tailor gender-sensitive programs. 59
Conclusions
Training of farmers seems to improve their knowledge and practice when handling pesticides as well as that of their fellow farmers. The training of pesticide dealers also seemed to have improved their performance also when it comes to counseling farmers. On this background, an improved extension service to farmers is recommended. However, we noted some bottlenecks such as market dynamics, availability of PPE, and the lack of alternative means of pest control on the markets that hindered transformation of knowledge into practice.
Footnotes
Acknowledgements
The authors would like to acknowledge the contributions made by all the stakeholders including the respondents (key, fellow, and control farmers and pesticide retailers). They highly appreciate the contributions made by the members of the Central Steering Committee and District Advisory Committee of the FHEN project. They thank the local cooperative bodies and IPM coordinators for their support to the project. In addition, they are thankful to Professor Dr Shree Krishna Giri for his contribution as the Project Coordinator during the initial period of the project. Finally, they thank all the staffs and members of Nepal Public Health Foundation. They sincerely acknowledge the technical assistance of the International Center for Occupational, Environmental and Public Health (ICOEPH) and Dialogos.
Peer review:
Four peer reviewers contributed to the peer review report. Reviewers’ reports totaled 604 words, excluding any confidential comments to the academic editor.
Funding:
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is supported by the CISU/Danish Government.
Declaration of conflicting interests:
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Author Contributions
EJ, BRP, DG, ST, and AV conceived and designed the experiments; agree with manuscript results and conclusions; and made critical revisions and approved final version. DG, AV, and EJ analyzed the data and jointly developed the structure and arguments for the paper. AV and DG wrote the first draft of the manuscript. DG, EJ, BRP, and ST contributed to the writing of the manuscript. All authors reviewed and approved the final manuscript.