Abstract
Background: Outdoor workers are exposed to hot work environments and are at risk of heat-related morbidity and mortality. The purpose of this study was to evaluate the knowledge of migrant farmworkers about first aid for heat-related illness (HRI) symptoms. Methods: The authors recruited 60 migrant farmworkers out of 66 who were approached from vegetable farms in Georgia. They were workers who participated in the 2018 Farmworker Family Health Program (FWFHP). The authors surveyed the workers to assess demographics, prevalence of HRI symptoms, hydration practices, and knowledge of HRI first aid. Descriptive statistics for worker demographics, HRI symptoms, and hydration data were calculated, as were the percentages of correctly answered pilot questions. Findings: Of the 60 workers who chose to participate in this study, more than 50% incorrectly answered pilot questions related to their knowledge of HRI first aid. The two most common HRI symptoms reported were heavy sweating and muscle cramps. More than two thirds reported experiencing at least one HRI symptom during the workday. Mean liquid consumption within this sample was 72.95 oz per day, which is much less than the recommended 32 oz per hour. Conclusion/Application to Practice: Until larger structural change can occur to protect farmworkers, farm owners can prevent morbidity and mortality from inadequate hydration practices and working in high-heat conditions by providing migrant farmworkers with training in heat-related first aid. Appropriate heat-illness interventions should focus on first aid measures to reduce morbidity and mortality related to heat illness in farmworkers.
Background
Globally, the last 5 years have seen the hottest surface temperatures in the modern era (Cole, 2019). Occupational heat exposure is of particular concern as workers who labor in the heat for extended periods of time are at risk of multiple heat-related health issues, such as: dehydration, heat-related illness [HRI], and heat stroke (Spector et al., 2016; Wesseling et al., 2016). Empirically, the negative effects of working long hours in the heat has been demonstrated in migrant farmworkers from several U.S. states (Arcury et al., 2015; Mix et al., 2018; S. Moyce et al., 2016). By engaging in work requiring physical exertion in the heat, farmworkers are at risk of adverse health outcomes, such as HRI (S. Moyce et al., 2017), acute kidney injury (Mix et al., 2018), and even death (Horton, 2016).
In 2016, the National Institute for Occupational Safety and Health (NIOSH) released revised Criteria for a Recommended Standard: Occupational Exposure to Heat and Hot Environments (Jacklitsch et al., 2016). Beyond the general heat-illness prevention strategies and controls, NIOSH underscores the importance of appropriate first aid training for outdoor workers to prevent morbidity and mortality for workers in hot environments. This is particularly relevant for agricultural workers in rural areas because emergency medical response times are twice as long than in urban areas (Mell et al., 2017), and workers have an increased risk of exposure to high heat during the workday (S. C. Moyce & Schenker, 2018).
During the 2018 Farmworker Family Health Program (FWFHP), which provides healthcare services for 2 weeks every summer to farmworkers and their families across farms in Central Southern Georgia, a farmworker died while working in the fields (Mauldin, 2018). This led to the creation of a pilot study aimed at identifying gaps in farmworker knowledge related to HRI first aid in the field.
Methods
This pilot study aimed to evaluate the knowledge of migrant farmworkers in Southeast Georgia on HRI first aid. We utilized a cross-sectional design and asked farmworkers to answer a 15-minute survey on their work environment, hydration practices, and knowledge of HRI first aid. As compensation for participating, farmworkers received a cooling bandana and training on how to properly use the bandana. This study was conducted simultaneously with farmworkers acquiring health care through the FWFHP, which is a mobile, worksite clinic that includes multiple clinic stations. We recruited participants only after they had entered the mobile clinic, and they were interviewed while waiting for care. Participants were reassured that their participation in the survey would not affect their ability to receive care.
Study participants were farmworkers working in field crop farms in Central Southern Georgia who participated in the FWFHP. Adult farmworkers were recruited during “night camps” in which mobile health clinics were set up on farms that invited the FWFHP to provide care for workers. As part of the night camps, workers were routed between the various stations that were staffed by nursing, nurse practitioner, physical therapy, dental hygiene, and pharmacy students. To take advantage of the way in which workers made their way through these night camps, a research station was incorporated that allowed a research team of bilingual nurse scientists to administer the study survey.
Workers were recruited during the second week of the FWFHP across four different farms from 7 p.m. until the end of night camp, which ranged from 9 p.m. to 12 a.m. A few workers approached the research station and inquired about the new table. However, the majority of workers were recruited by word-of-mouth from night camp staff, the research team, and other workers. Of the workers who we explained the study to, six declined to participate due to uncertainty about the study, whereas the remainder agreed to participate. Ultimately, 60 workers agreed to participate and were consented. Workers were then administered the survey, which could either be administered at the research station or while workers were waiting for services at any of the other stations. Once the survey was complete, workers were compensated with evaporative cooling bands and a demonstration of how to properly utilize them during the workday. The study was approved by Emory University Institutional Review Board and the State of Georgia Department of Public Health Institutional Review Board.
Survey Development
The survey was adapted from the Questionnaire for Heat-Related Illness Among Migrant Farmworker Populations in Southern Georgia developed by Fleischer et al. (2013) to characterize demographic information, years worked in the United States, HRI symptoms, and hydration status during the workday. Workers were asked whether they had experienced any of the following symptoms during the workday: heavy sweating, headache, nausea or vomiting, confusion, dizziness, fainting, or sudden muscle cramps. In addition, workers were asked which types of liquids they consumed for hydration (i.e., water, coffee, tea, juice, soft drinks, sports drinks, energy drinks, or alcohol) and to estimate how much of each different type of liquid was consumed during the workday, in which they were shown pictures of various sizes of drink bottles to help estimate the amount.
Pilot questions were developed based on current NIOSH guidelines for occupational heat-exposure safety (Jacklitsch et al., 2016) to assess workers’ current knowledge related to HRI first aid in the agriculture field–based setting. The pilot knowledge questions asked about length of time it takes a worker to acclimatize to working in the heat; identification of the appropriate anatomical locations to place cold packs on someone experiencing heat illness; identification of the symptoms that someone might display if suffering from heat illness; the number to use to call emergency services; how long to wait before calling emergency services after someone shows signs/symptoms of heat illness; identifying the appropriate first aid measures, such as how fast to cool someone experiencing heat stress, how fast to drink water if experiencing heat stress, and encouraging coworkers to push through feelings of irritability and dizziness; and appropriate use of the buddy system if it is suspected that a coworker is experiencing heat stress. For a full list of the questions asked, options provided, and the corresponding correct answers, see Supplemental Table S1. Subsequently, the questions were translated into Spanish by a certified English–Spanish translator.
Data Analysis
Once collected, all data were uploaded into REDCap, a secure online platform that stores survey data. All data were analyzed using R version 3.5.3. Descriptive statistics for the demographic data, symptom prevalence, and hydration during the work day were calculated. The pilot questions assessing knowledge of HRI first aid were analyzed by calculating the percent of correct responses by farmworkers to the questions.
Results
A total of 60 farmworkers participated in this study, with age that ranged from 18 to 51 years, with a mean age of 28.75 years (SD = ±7.05 years). About 82% of the sample were born male/identified as male, 100% were Hispanic, 92% identified as Mexican, and 95% spoke Spanish as their primary language (Table 1). More than half of the farmworkers were married and had an average of 8.78 years (SD = ±3.44 years) of education. Participants had worked, on average in agriculture within the United States for 2.74 years (SD = ±3.99 years) and began working in agriculture at 19.08 years of age (SD = ±6.02 years).
Sociodemographic, Health, Work, and Environmental Characteristics of Migrant Workers (n = 60)
During the workday, farmworkers who reported drinking water (n = 59) drank an average of 72.95 ounces (oz; SD = ±43.76 oz), farmworkers who reported drinking sports drinks (n = 32) drank an average of 34.25 oz (SD = ±23.23 oz), farmworkers who reported drinking soft drinks (n = 24) drank an average of 23.20 oz (SD = ±11.47 oz), and farmworkers who reported drinking energy drinks (n = 4) drank an average of 13.10 oz (SD = ±3.66 oz). Workers also reported varying numbers of HRI symptoms, with approximately 68% of farmworkers having experienced at least one HRI symptom and 12% having experienced three or more HRI symptoms. The most commonly reported HRI symptom reported was heavy sweating (50%), followed by cramps (25%), headache (22%), dizziness (10%), and nausea (3%). There were no reports of confusion (0%) or fainting (0%).
Results of the knowledge-based questions were classified as selecting the correct information or not. A total of 27% of workers were able to correctly identify the amount of time to acclimatization (Table 2). Workers identified 10 HRI symptoms, resulting in 77% of workers identifying at least three HRI symptoms, 35% were able to identify at least six HRI symptoms, and only 7% were able to identify at least nine HRI symptoms. Less than half (45%) of workers were correctly able to identify that a person can experience a heat stroke and still actively sweat.
Results From Pilot Questions Testing Knowledge of Heat-Related Illness First Aid Among Migrant Farmers (N = 60)
With respect to stating the number to call in the event of an emergency, exactly half of the sample correctly identified 911 and only 20% were able to identify the time between symptom onset and calling 911. When a coworker appears symptomatic (e.g., irritable or dizzy), 95% were able to identify that that they should accompany the coworker during a water break, 42% were able to identify that the coworker should not be encouraged to drink large amounts of water rapidly before resting alone, 78% were able to identify that the coworker should not be told to push through their symptoms, and 0% were able to identify that a coworker should not rest alone. When a coworker is having a heat stroke, 97% were able to successfully identify that they should stay with the coworker, 100% identified that the coworker should be moved to the shade, 23% identified that they should not wait to remove the coworkers outer clothing and begin cooling, and 33% identified correctly that the coworker should be cooled rapidly. Only 70% could identify one of the three anatomical locations that cool towels or ice should be applied to a person with heatstroke.
Discussion
It is known that farmworkers are at increased risk to suffer from morbidity and mortality related to heat exposure (Arcury et al., 2015; Gronlund, 2014; Mirabelli et al., 2010; Quandt et al., 2013). These risks are further compounded by the lack of access to health care that is common in rural areas such as South Georgia (Douthit et al., 2015; Thierry & Snipes, 2015). When comparing the part of the results of this study with those of Fleischer et al.’s (2013), which was completed in a similar population of migrant farmworkers in south Georgia, the risk of HRI had not decreased since the publication of Fleischer et al. In both samples, farmworkers reported experiencing HRI symptoms during the workday and inappropriate hydration measures by consuming less than the 32 oz of water per hour that is recommended when working in high heat conditions (Occupational Safety and Health Administration, n.d.). This highlights the need for further action to help prevent mortality and morbidity related to HRI in farmworker populations.
Knowing what symptoms to look for in employees and coworkers and the approximate actions to take in mild heat illness as well as a heat-illness emergency is an attainable goal that has potential to save many workers’ lives. Efforts that focus only on the prevention of heat illness through mantras of water, rest, and shade may fall short in day-to-day detection of workers who need assistance and leave dedicated coworkers empty-handed when wanting to intervene when someone is in trouble. There have been multiple documented accounts of unsuccessful attempts of coworkers and crew leaders acting to rescue a coworker suffering from severe heat illness (Khokha, 2008; Mauldin, 2018; Perez, 2016). These events could have been avoided with the provision of appropriate first aid supplies and knowledge and training in what actions to take. Furthermore, a safety-oriented focus is needed by employers and crew leaders to promote a supportive culture for these preventive heat-illness first aid efforts.
In our sample, the majority of workers were inclined to wait before attempting to cool down a coworker. In addition, in our sample, a greater number of those who were born female/identify as female than those who were born male/identify as male were able to correctly identify that a coworker experiencing heat stress should be cooled quickly. It is a common myth that a person should not be cooled quickly when experiencing HRI symptoms. However, current clinical guidelines are that cooling of an individual suffering from heat stress should occur immediately upon identification of symptoms, particularly if the person has altered sensorium (Lipman et al., 2019). Ideally, a person experiencing moderate to severe heat illness (i.e., they are disoriented or confused, have fainted, or are suffering from heat stroke) should be treated with cold-water immersion. However, in the absence of the ability to do so, ice packs or towels immersed in cold water can be applied to the neck, axillae, or groin (Lipman et al., 2019). The average length of time having worked in the United States was just less than 3 years. It is possible that in this time period, workers had experienced misinformation related to HRI first aid and, therefore, were more likely to wait when cooling a coworker experiencing heat illness.
Of the 13 participants who incorrectly stated that they should tell a coworker who was dizzy to push through their work, all were men. We could not confirm why this trend existed. However, as explained by Horton (2016), machismo is still practiced in many farmworker populations in the United States. It was possible that those who were born male/identify as male, were telling each other to “push through” any HRI symptoms or are not disclosing their symptoms to their coworkers to maintain the status quo that has been set in place by machismo culture. Interestingly, only 50% of the workers knew the number to call for emergency services. Given that 98% of the sample identified as either “Mexican” or “Mexican American,” the proportion of those knowing 911 was expected to be higher because the number of emergency services in Mexico is also 911 (Associated Press, 2017).
It has previously been suggested that farmworkers desired and could benefit from additional training related to heat illness (Fleischer et al., 2013; Stoecklin-Marois et al., 2013). The results of this study further highlighted the need for this training, with a focus on heat-related first aid due to the risks experienced by farmworkers when working in the heat during the summer months. In addition, these results provided evidence that farmworkers lacked the appropriate levels of knowledge required to identify and prevent morbidity and mortality related to occupational heat exposure.
If farmworkers can be effectively trained to identify the signs and symptoms of HRI, earlier action can be taken to prevent the negative consequences associated with working in the heat. The ultimate impact of developing an intervention to empower farmworkers about HRI would be twofold. First, farmworkers would be able to identify the signs and symptoms of HRI and take the appropriate measures necessary to prevent further deterioration of themselves or a coworker experiencing HRI. Second, rural areas experience longer response times after calling emergency medical services (Mell et al., 2017), and by training farmworkers in HRI first aid, they can begin to provide evidence-based heat-illness first aid while waiting for emergency medical services to arrive. Robust heat-related first aid training for farmworkers will require the support of crew leaders and employers through the provision of preventive resources (i.e., water, shaded areas for rest, and adequate rest breaks) as well as regular training of supervisors and company-wide policies that support and promote heat-related first aid actions.
This study had several limitations. First, this study was cross sectional in nature and causation cannot be inferred. At best, an educated guess at why farmworkers lack knowledge related to HRI first aid may be made when designing a future intervention. In addition, the majority of farmworkers in this sample (68%) were workers on the same farm. The logistics of the FWFHP made it so that two out of the four data collection days occurred on the same farm. However, this is the nature of completing community-based studies, and when working with community partners to collect data, sometimes researchers must work within the constraints of the community partner. Finally, the scope of this article is the heat-related knowledge and practices of farmworkers and does not include similar information on crew leaders and other supervisors. Future studies will be needed to determine what training is needed of supervisory staff and employers to best support the health of farmworkers.
Implications for Occupational Health Practice
Ultimately, these results will be used in the development of an intervention to improve farmworker knowledge on HRI first aid. Recommendations for heat-illness prevention include measures such as adequate acclimatization and reducing heat exposure (Leyk et al., 2019). However, curative measures to cool the body (e.g., ingestion of ice, applying cold packs to the body, or immersion of the body in cold water) are the only way to prevent morbidity and mortality related to heat stroke (Brearley, 2016; Leyk et al., 2019). Therefore, given the rural nature of South Georgia, we propose developing an intervention that targets the crucial time between recognition of heat-illness symptoms and medical care arriving. Ideally, the intervention will be designed in a way that allows it to be delivered as part of the yearly FWFHP and can be shared with the Georgia Department of Public Health so that the greatest number of farmworkers can be reached throughout the year. These interventions should also be designed with considerations for cultural beliefs, such as the documented impact of the hot–cold dichotomy on Latino farmworkers’ health and well-being (Barker et al., 2017; McCullagh et al., 2015). These results do not only apply to the development of interventions with heat-exposed workers in Georgia but also support the need for developing heat-illness prevention measures with heat-exposed agricultural workers across the country.
Conclusion
Given the current climate crisis, farmworkers are at an increased risk of experiencing HRI while at work. In areas, such as rural Georgia, this risk is compounded by lack of knowledge related to HRI first aid, suboptimal hydration measures, and increased response time of emergency medical services. This study has provided baseline data on national guideline-based questions that have highlighted areas for additional teaching needs within farmworker communities. The results of this study will be used to develop a guideline-based training course for employers, crew leaders, and workers to improve knowledge and competence in HRI first aid for South Georgia within the FWFHP. We encourage others working with farmworker populations to further assess HRI knowledge and develop tailored interventions to address any knowledge deficits in the populations they serve.
Applications to Occupational Health Practice
In response to a farmworker death, this assessment of first aid knowledge related to HRI and hydration practices was deemed necessary and timely to the community in which data collection occurred. The results of this study will be used to create an HRI training program tailored to farmworkers throughout South Georgia. The intervention will be developed and tested with the FWFHP and ultimately scaled-up for use in public health clinics throughout Georgia. Furthermore, we encourage occupational health professionals working with migrant farmworkers to conduct similar research and develop interventions that can help protect their communities from the deleterious effects of increasing global temperatures.
Supplemental Material
WHS-20-0050_Supplemental_Table – Supplemental material for Knowledge of Heat-Related Illness First Aid and Self-Reported Hydration and Heat-Related Illness Symptoms in Migrant Farmworkers
Supplemental material, WHS-20-0050_Supplemental_Table for Knowledge of Heat-Related Illness First Aid and Self-Reported Hydration and Heat-Related Illness Symptoms in Migrant Farmworkers by Daniel J. Smith, Erin P. Ferranti, Vicki S. Hertzberg and Valerie Mac in Workplace Health & Safety
Footnotes
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.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Supplemental material
Supplemental material for this article is available online.
Author Biographies
Daniel J. Smith is a PhD candidate and clinical instructor at the Nell Hodgson Woodruff School of Nursing at Emory University. He is also a Robert Wood Johnson Foundation Future of Nursing Scholar.
Erin P. Ferranti is an assistant professor at the Nell Hodgson Woodruff School of Nursing at Emory University. She also serves as the director of the school’s Farmworker Family Health Program.
Vicki S. Hertzberg is a professor and biostatistician at the Nell Hodgson Woodruff School of Nursing at Emory University. She also serves as the director of the school’s Center for Data Science.
Valerie Mac is an assistant professor at the Nell Hodgson Woodruff School of Nursing at Emory University. She also serves as an academic liaison to many farmworker health organizations within the United States and globally.
References
Supplementary Material
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