Using History and Accomplishments to Plan for the Future

Public Health Perspectives

Editor's Note: ASH-NET sought the review of and advisement on this document by a public health professional with experience working within the agricultural community. Natalie Roy, MPH, Business and Development Director of the AgriSafe Network, graciously agreed to provide this needed perspective on the document contents along with specific suggestions related to the interface of public health and agricultural issues at the federal, state, and local levels.

Document Applicability

The Institute of Medicine's Future of Public Health report has summarized public health practice as involving three core functions (IOM 1988):

• Assessment-of a community's health and its resources
• Policy development-to promote health and solve health problems
• Assurance-that access to health care, promotion, and prevention services are available

The recommendations outlined in this document include all three core components and the essential public health services that are included in the core components. Adapted from the Ten Essential Public Health Services of the U.S. Department of Health and Human Services (USDHHS 1995), these 10 services are depicted throughout this document and reflect the unique health and safety needs of the agricultural community:

• Monitoring health status to identify health problems of the agricultural community
• Diagnosing and investigating health problems and health hazards in the agricultural community
• Informing, educating, and empowering farmers about health and safety issues
• Mobilizing community partnerships to identify and solve agricultural health and safety problems
• Developing policies and plans that support individual and community health efforts
• Linking farmers to needed personal health and safety services and ensure the provision of health care when otherwise unavailable
• Enforcing laws and regulations that protect health and ensure safety
• Assuring a competent public health and personal health workforce with training in the field of agricultural health and safety
• Evaluating effectiveness, accessibility, and quality of personal and population-based health and safety services for the agricultural community
• Researching for new insights and innovative solutions to health and safety problems

The most effective prevention works at multiple levels-federal, state, and local-simultaneously. Although this document focuses primarily on federal initiatives, success is dependent on the actions of different agencies, researchers, educators, health professionals, and policymakers, each of which is integral to achieving the goal of a healthier and safer agricultural community.

The National Institute for Occupational Safety and Health (NIOSH) and other CDC centers, such as the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), are focusing on the integration of research findings into public health practice. This document, which was developed by researchers, practitioners, and farmers, outlines recommendations that require an interdependence between those working in the field of research and those providing services. The research priorities listed in this document are based on program needs and direction from the agricultural community. In turn, the service and training priorities listed in this document are based on research findings conducted in the past.

Figure 1 (taken from the research agenda of NCCDPHP) illustrates the positive feedback loop of translating research into practice.



Public Health Interfacing with Agriculture

Centers for Disease Control and Prevention

1. The Public Health Practice Program Office (PHPPO) within CDC should integrate agricultural health and safety distance learning in the course offerings supported through the Public Health Training Network (a program of PHPPO). PHPPO provides distance learning courses on a variety of topics with the intention of strengthening the public health workforce. Inclusion of agricultural health and safety distance learning courses would reach a broad audience of public health practitioners. Academic institutions that are leaders in the field of agricultural health and safety could collaborate with PHPPO to develop distance learning courses.
2. The National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), a center of CDC, should develop and test Behavioral Risk Factor Survey (BRFS) modules that measure the health and safety needs of the agricultural community. Pretested standard core questions would enable health professionals to make comparisons between states to establish national agricultural health and safety priorities.

State Public Health Professionals and Policymakers

State public health professionals and policymakers working in state offices can have a significant impact in improving the health and safety of the agricultural community. Examples of state agencies that have focused efforts on the farming population include, but are not limited to, Departments of Public Health, Insurance Commissions, Transportation Departments, Departments of Education, and Departments of Agriculture.

1. Include questions about occupation type and farm-related illnesses and injuries in the Behavioral Risk Factor Survey (BRFS). The Behavioral Risk Factor Surveillance System (BRFSS) is a telephone survey conducted by all state health departments, the District of Columbia, Puerto Rico, the Virgin Islands, and Guam with assistance from CDC. States use BRFSS data to track critical health problems and to develop and evaluate public health programs. The system is flexible and allows for the addition of questions to meet the needs of each state. States should consider developing and including questions that specifically relate to the health and safety issues of the agricultural community. New Hampshire, for example, used BRFSS data to highlight differences between rural and urban health risk behaviors. The report was then used to justify the need for a State Bureau of Rural Health. The same approach could be taken to examine differences in agricultural and nonagricultural risk behaviors.
2. State-based insurance reform often centers on decreasing the number of citizens who are uninsured. The majority of farmers, however, are considered underinsured, indicating limited coverage and limited access to preventive services. Health insurance plays a critical role in ensuring that people obtain timely medical care that is appropriate. In an era of high health care costs, individuals' difficulty in affording medical care has made health insurance essential for ensuring that health services are both accessible and affordable. In a 2001 study conducted with farmers in Northwest Iowa, both men and woman with coverage from a self-purchased plan were less likely to receive important preventive services than those farmers covered by an employee sponsored plan. Particular attention was given to differences found among employee-sponsored versus self-purchased plans. The importance of this distinction is to highlight the significance of evaluating the type of coverage and not merely whether someone has coverage. Too often policies or pilot programs focus on decreasing the number of uninsured, with very little emphasis on the quality of health coverage. A farmer with an insurance policy that covers only major medical costs is most likely not receiving adequate care compared with those with full coverage.

Health Care Providers and Community Educators

1. When county need assessments or other types of surveys are conducted in rural areas, occupation type should be captured in order to examine the unique health and safety needs of the farming population. Initiatives intended to improve rural health often do not address the unique health needs of farmers, seasonal farmworkers, and migrant workers. Collecting data by occupation can define differences in access to care, utilization of care, and health status among the agricultural an non-agricultural community.
2. To ensure that farmers are not lost in the health care system, local service agencies need to develop strategies to coordinate, enhance, and expand access to health care. In addition to developing an extensive referral system with health care providers, other entities such as extension services, schools, agribusinesses, commodity groups, religious organizations, and health and human service agencies can assist in the promotion of agricultural health and safety issues. Public awareness programs can be held in conjunction with community activities such as pesticide applicator training sessions and local vocational agricultural classes at community colleges and high schools.
3. All health professionals working in locations where agriculture is prevalent should receive continuing education in the field of agricultural health and safety. Farmers are much more apt to value services offered by providers who understand their unique occupational health problems and the nature of their work life on the farm. Valued services, in turn, lead to better understanding of preventive care and adoption of safe work practices. Therefore, the more professionals can learn about the farm work environment, the better equipped they will be in providing services. For example, the Center for Agricultural Safety and Health at the University of Iowa provides intensive continuing education in the field of agricultural health and safety.
4. Health care providers should take an active role in improving the quality and reducing the cost of health insurance coverage for farm families. Various health and social service organizations strive to provide care to the farming population without understanding the financial obstacles that can reduce utilization of much-needed care. Local health providers should examine the health insurance problems unique to their community, especially if these problems reduce access to care. In a 2001 study in northwest Iowa, farmers in the lowest income bracket were the most likely to lack health coverage. Interestingly, it is these farmers who would be eligible for either Medicaid or the Children's Insurance program. Health providers can take an active role in promoting the use of government funded programs for those farm families who are eligible.
5. Health professionals should collaborate with community colleges and universities to access resources, model programs, and technical assistance related to agricultural health and safety. Health professionals who develop partnerships with academic institutions can obtain important resources to enhance the care they provide to the agricultural community. For example, occupational health histories initially used for research purposes may be beneficial to the clinician in directing patient care.
6. Include cause of injury (farm related, non-farm related) and occupation when entering admission data at the emergency room. Important data on the prevalence of agricultural related injuries is often lost because the appropriate information is not gathered during the emergency room visit. If adequately captured, such information can help health and safety specialists focus efforts and resources on the areas of greatest need.
7. Engage farmers and farm workers in identifying and improving the health and safety needs of the community. Too often health care professionals determine the needs of a community or an individual. Establishing a local advisory board with strong representation from actual farmers is a logical approach to ensure that health services are responsive to the community's needs on an ongoing basis. The Public Health Practice Program Office, a department within the CDC, has published a resource guide entitled Principles of Community Engagement. Protocols detailed in the guide can be used to engage the agricultural community in the planning process.

Natalie Roy, MPH
Business and Development Director
AgriSafe Network
www.agrisafe.org

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