https://orcid.org/0000-0002-0260-7493
ABSTRACT
Occupational and environmental exposures in the agricultural industry have been associated with several illnesses and poor health outcomes. Information regarding the characteristics and health status of the labor force working in the agricultural sector in Puerto Rico is limited. The overall objective of this study was to increase the available information on agricultural workers health and needs by ascertaining the potential differences in characteristics and health status of farmworkers when compared to the general population in rural Puerto Rico This cross-sectional study used the collection and analysis of medical records of agricultural workers and non-agricultural workers in Hospital General Castañer, located in Lares, Puerto Rico. The research period was five years, from 2012 to 2016. This research described agricultural workers’ demographic and socioeconomic profile and evaluated relationships between one or more demographic variables and farmer’s health. Agricultural workers presented alower prevalence of hypertensive disease (69.4%) and ahigher prevalence of cerebrovascular disease (3.4%) when compared to non-agricultural workers. In other words, agricultural workers were 21% less likely to have hypertensive disease as compared to non-agricultural workers. Results for agricultural workers showed that 4.0% of the workers were diagnosed with arthritis, and 48.8% had suffered at least one type of dorsopathy. The results from this research provide useful information for developing an appropriate framework to address Puerto Rican agricultural worker’s health while promoting the agricultural industry development on the island. Finally, this study provided insight into the prevalence and demographic characteristics of agriculture workers in acentral region of Puerto Rico. Further efforts are needed to better define the agricultural workers and farming communities in Puerto Rico that may be exposed to related hazards.
Introduction
Agricultural workers are exposed to numerous environmental, biological, chemical, and physical hazards. These exposures, over long periods, may result in diseases and conditions such as arthritis, noise-induced hearing loss, pesticide poisoning, zoonotic diseases, and noninfectious diseases.Citation1 Several studies indicate that agricultural populations have a better health status than the general population or non-farm population when considering behavioral factors such as tobacco use, alcohol consumption, active lifestyle, and a healthier diet .Citation2 However, other studies found an elevated prevalence of several chronic diseases in this population, including obesity, high blood pressure, and high serum cholesterol .Citation3,Citation4 In addition, studies about respiratory diseases such as chronic obstructive pulmonary disease (COPD), show that 15%–20% of cases in agricultural workers have been attributed to occupational exposures .Citation5 Furthermore, studies have shown that non‐cancer illnesses (e.g., heart disease and diabetes, among others) accounted for 56.2% of the fatalities in the studied farmer population .Citation2 However, research targeting the etiology of illness in agricultural settings has not conclusively identified which labor conditions are the origins of some of the above-mentioned health conditions.
The Center for Disease Control and Prevention (CDC), through the National Institute for Occupational Safety and Health (NIOSH), carried out the National Health Interview Survey (NHIS) from 2004 to 2013 and published the Chronic Conditions Charts. The survey presented prevalence for various chronic conditions using data collected from personal household interviews. For monitored conditions, prevalence (95% CL) was calculated, resulting in the following: asthma (3.9%), diabetes (5.31%), hypertension (24.9%), and dermatitis (5.5%), among others .Citation6 The combination of the physical demands and the long work hours of agricultural work results in a vulnerable scenario for an already vulnerable population .Citation7
Agriculture worker data in Puerto Rico
The information regarding agricultural activity in Puerto Rico is highly oriented to economic development. Most of the Puerto Rico Department of Labor and Human Resources (DLHR) and USDA’s Census of Agriculture reports present the agricultural activity in terms of profits and production; little emphasis is given to the conditions or characteristics of the workforce. Both of these reports discuss few demographic characteristics of agricultural workers and/or farmers. However, little or no attention is giving to occupational health, and data on the prevalence of chronic diseases, other than cancer, is limited when it comes to the agricultural worker population.
This study aimed to determine the prevalence of chronic disease among agricultural workers in a rural area in Puerto Rico. The overarching goal of this study was to assess whether the risk of having a selected chronic disease is different for agricultural workers than for non-agricultural workers. Target conditions included diseases related to the respiratory system, cardiovascular system, musculoskeletal system, genitourinary system, metabolic disorders, and skin-related diseases. In addition, the distribution of demographic and socioeconomic characteristics, including rates of underlying medical conditions, access to health care, and other social factors was also analyzed. Understanding how these diseases are distributed among workers helps to lead prevention efforts and the identification of possible occupational exposures. In addition, this provides valuable information for future investigations. Finally, knowing the prevalent conditions in a specific occupational population can help shape the formulation public policy and health services to address their needs.
Methods
Study location
Castañer is in the central region of Puerto Rico, where a large part of the island’s agricultural activity takes place. When considering the possible hazards faced by agricultural workers, there are three types of hazards in the area: chemical, biological, and physical. In terms of exposure to chemicals, self-reported pesticide use, including insecticides, fungicides, and herbicides, are recorded by Hospital General Castañer (HGC), a primary healthcare facility. The related health effects of the identified pesticides include cancer and negative effects on the nervous, respiratory (asthma), renal, and cardiovascular systems.
Conversely, Castañer is located in the rural and mountainous regions of Puerto Rico; therefore, agricultural fields and crops are in hills and/or uneven terrains, presenting a physical hazard for agricultural workers related to musculoskeletal disorders. Finally, biological hazards related to agricultural activities include exposure to biological agents, vector transmitted viruses, fungus and bacteria and animal bites in the workplace.
In Castañer, primary health services specialized in agricultural workers are mostly provided through HGC, which is a primary healthcare center founded by the U.S. Health Resources & Services Administration (HRSA). HGC’s main population is agricultural workers, which comprise 43% of their patients. The facility’s patient reports present with a prevalence of various chronic diseases such as asthma (7%–9%), COPD (1.11%–1.71%), hypertension (23%–25%), and heart disease (5%), among other conditions. Health centers whose primary population is composed of agricultural workers act to establish programs that focus on educating on the hazards of agricultural work and how to protect farmworkers’ families, providing culturally appropriate enrollment assistance, linkages to other community resources, and proper primary care. To do this, it is important for these health centers to know the health status and needs of their target population.
Variables of study
This study included analysis of several variables, including sociodemographic and economic characteristics, and the presence of diagnostic evaluations in the medical record. The definition of sociodemographic and economic characteristics are based on medical record forms. For the identification of the group of interest, the community health center identifies agricultural workers using the definition presented in Section 330(g) of the Public Health Service Act as:
“an individual whose principal employment is in agriculture, who has been so employed within the last 24 months, and who establishes for the purposes of such employment a temporary abode” or “an individual whose principal employment is in agriculture on a seasonal basis and who is not a migratory agricultural worker”.Citation8
Patients that did not meet these criteria were classified as “non-agricultural workers.” For the purpose of this study, “non-agricultural workers” were patients from the general population receiving medical treatment or health services at HGC. This population, although identified as not performing agricultural work, can be a dependent or cohabitant of an agricultural worker.
The presence of a condition was based on physician diagnosis. Health conditions related to the respiratory system included asthma and COPD. Asthma is characterized by airway inflammation symptoms and variable and chronic airflow limitations, and it has several risks and casual factors, including occupation .Citation9 COPD is defined as a “common inflammatory disease of the airways characterized by chronic obstruction of airflow that is not fully reversible” .Citation10 In addition, circulatory system conditions such as cerebrovascular disease and hypertensive disease, which are disorders related to the heart and blood vessels, were studied. Furthermore, of musculoskeletal diseases, only dorsopathies were included. These are defined as disorders in the back or spine. The definition of the health condition and its presence were established by the ICD correspondent to the year being analyzed.
Statistical analysis
All chronic disease data were reconciled, categorized, and merged. Disease diagnostics were classified in binary categorical values: having the condition or not having the condition. Information was grouped in the targeted conditions. The descriptive analysis included calculation of proportions for all categorical variables. A comparison between agricultural workers and non-agricultural workers was completed using the Chi-squared test for sociodemographic and health status variables. Association variables and agricultural workers and non-agricultural workers status were assessed using logistic regression analysis. The strength of associations was described using the prevalence odds ratio (POR) and 95% confidence intervals (CI). All analyses were performed using Stata 15 software.
Study subjects
The sample size of the study included all patients who receive services during the 5-year period (2012–2016), and who met the age criteria (18 years and older). Subjects under 18 years old were excluded from the study, since there was no information available about their occupational status. A total of 2,964 records were analyzed using the agricultural worker status given by HGC.
Demographic characteristics are presented in . Agricultural workers had a higher percentage of males (38.7%) than non-agricultural workers (28.2%) and lower percentage of females (61.3%) when compared with non-agricultural workers (71.8%). The age distribution was different for both groups, with the agricultural workers having a higher percentage in age groups from 45 years and older and a lower percentage in age groups of 44 years and younger. For both groups, agricultural workers and non-agricultural workers, the largest percentage of subjects were in the group of 65 years or older (31.1% and 29.3%, respectively), whereas the lowest percentage pertained to the age group of 24 years or younger (2.8% and 4.6%, respectively). The location of subjects was identified using the address provided by the patients as “residential address.” Although both groups had a high percentage of subjects residing in Adjuntas, it was higher for non-agricultural workers (67.7%) when compared with agricultural workers (58.6%). Alternately, more agricultural workers reported living in Castañer (16.1%) and Lares (15.1%) when compared with non-agricultural workers (13.0% and 11.4%, respectively). Statistical significance was obtained in gender (p < 0.0001) and municipality (p < 0.0001), meaning that the distribution of females and males and the residence of the subjects was different for agricultural workers when compared to non-agricultural workers.
Table 1. Demographic Characteristics of Agricultural Workers and Non-agricultural Workers in Castañer, Puerto Rico from 2012 to 2016 (n = 2,964)
Socioeconomic characteristics of the population, including ethnicity, language, poverty level, and health insurance, are presented in . All the variables were restricted to the medical record specifications. Ethnicity was presented in dichotomous options as being or not being Hispanic, and language referred to which language was preferred by the patient with options being “Spanish” and “English”; for patients without a language assessment, the record showed the option “unknown.” Statistical significance was obtained for the distribution of ethnicity (p < 0.05) and language (p < 0.001).
Table 2. Socioeconomic Characteristics of Agricultural Workers and Non-agricultural Workers in Castañer, Puerto Rico from 2012 to 2016 (n = 2,964)
Income information is presented in terms of the “poverty level” using the 2016 Federal Poverty Level Guidelines. There were four categories for health insurance: uninsured, private, public, and Medicare. Those classified as “private” included patients that paid for insurance or service on their own or who were covered by an employer. For the poverty and health insurance variables, data showed that most of the patients (73.7%) were 100% or below the poverty level, and that 71.4% of them were enrolled in the Puerto Rico government health insurance plan. For patients classified as 100% or below the poverty level, similar percentages were obtained for both agricultural (74.4%) and non-agricultural workers (72.1%). In contrast, patients classified as 100%–150% of the poverty level were higher in the non-agricultural workers (9.8%) when compared with agricultural workers (6.0%). For these economic variables, statistical significance was obtained for poverty level (p < 0.01), but not for health insurance (p > 0.05), indicating there was a difference in the reported family income when comparing groups, but there was no difference in the ability to obtain health services. This, however, does not take into consideration other barriers that could be present for individuals who were trying to access health services such as residence distance and transportation.
Results
presents the results of prevalence for each of the health conditions included in the study. Prevalence is presented for each group, as well as for all the sample population. Moreover, the Prevalence Odds Ratio (POR) at a 95% CI was calculated to asses if the risk of having a selected chronic condition was higher for those who identified themselves as agricultural workers in the study population than those who identified as non-agricultural workers. In terms of the prevalence of asthma and COPD, both agricultural workers and non-agricultural workers showed similar results.
Table 3. Prevalence of Selected Chronic Diseases in Agricultural Workers and Non-agricultural Workers in Castañer, Puerto Rico from 2012 to 2016 (n = 2,964)
Respiratory conditions and other selected chronic diseases
The prevalence of asthma was 23.8% in agricultural workers and 23.7% in non-agricultural workers. When assessing diabetes, chronic kidney disease, and selected skin diseases, results shown that agricultural workers had a higher prevalence when compared to non-agricultural workers. At least 42.3% of farmworkers had diabetes, 7.6% were diagnosed with chronic kidney disease, and 5.4% had either dermatitis or eczema. Non-agricultural workers presented a prevalence of 40.7%, 7.1%, and 4.2%, respectively. The comparison of these previously discussed health conditions was not considered statistically significant.
Circulatory system
Prevalence of hypertensive disease and cerebrovascular disease was calculated for all subjects (69.7% and 3.4%, respectively) and each exposure group. Agricultural workers presented a lower prevalence of hypertensive disease (69.4%) and a higher prevalence of cerebrovascular disease (3.4%) when compared to non-agricultural workers. In the case of hypertensive disease, data had enough statistical significance to indicate that being classified as an agricultural worker was associated with a lower odds ratio of having the disease (POR <1). In other words, agricultural workers that received treatment in HGC during the study period (2012–2016) were 21% less likely to have hypertensive disease compared to non-agricultural workers receiving treatment in the same hospital.
Musculoskeletal system conditions
presents the prevalence and exposure association for arthritis and dorsopathies (backbone lesion) in agricultural workers and non-agricultural workers in Castañer. Results for agricultural workers showed that 4.0% of the workers were diagnosed with arthritis, and 48.8% had suffered at least one type of dorsopathy. Compared to agriculture workers, non-agricultural workers presented a lower prevalence in both disorders; 2.4% of the patients suffered from arthritis, and 44.9% had at least one type of dorsopathy. When assessing the association between being a farmworker and having a disease, the research showed that agricultural workers have a 69% higher chance of having arthritis than non-agricultural workers.
Discussion
This study aimed to determine if there was a difference between chronic health diseases in agricultural workers versus non-agricultural workers. Considering the physical demands of agricultural work and the need to often engage in repetitive movements, awkward positions, and heavy lifting, it was expected that farmworkers were at risk for musculoskeletal disorders. Agricultural workers included in the study presented a higher prevalence in dorsopathies and arthritis. In addition to occupational exposure, results could be attributed to age distribution in agricultural workers. Agricultural workers tended to work beyond retirement, adding age as one of the risk factors for this kind of disorder .Citation11
In previous research, skin diseases accounted for more than half of work-related illness in farmworkers .Citation12 Likewise, some studies have linked chronic kidney disease to farming communities and activities .Citation13 Even though the emphasis for addressing diabetes has been mostly related to lifestyle and genetics, evidence relating pesticide exposure to this disorder has increased .Citation14 While there was no statistical significance in the results, the prevalence of these diseases was higher in agricultural workers when compared with non-agricultural workers.
For chronic respiratory diseases, although there was no statistical significance in the comparison of the groups, the high prevalence of farmworkers and non-farmworkers diagnosed with those diseases is noticeable. While there was no strong association between having asthma and being an agricultural worker in Castañer, it is important to highlight that prevalence for all patients in the study was higher (23.7%) than that reported for the general Puerto Rico population (17.2%). Respiratory diseases are associated with occupational exposure of agricultural workers, especially when assessing pesticide exposure .Citation15 Although there are conflicting data regarding the casual factors and magnitude of this condition in farmworkers, studies suggest that the prevalence of COPD in these workers is higher than in other occupations and is dependent on the farming activity .Citation16 A high prevalence of these diseases could be indicative of inadequate worker protection and pesticide application methods.
The results showed that being an agricultural worker in Castañer may be a protective factor for hypertension (20% less risk than for non-agricultural workers). Further research should be carried out to determine if occupational characteristics such as work-related physical activity will explain this protective factor. Research regarding the prevalence of these disorders is inconsistent; some studies indicate that general morbidity (rate of disease in a population) is lower for agricultural workers when compared to non-agricultural workers .Citation17 Other research has found that agricultural workers have a higher prevalence when compared to non-farming occupations .Citation18 Regardless of these results, it is important to point out that the Castañer community (all subjects, n = 2,964) presented a higher prevalence of both hypertension (69%) and cardiovascular disease (3%) when compared to the reported prevalence in the general Puerto Rico population, where 36.8% of the population has hypertensive disease, and 1.7% have been diagnosed with cardiovascular disease. Finally, agricultural workers in Castañer also show a higher prevalence of asthma (23%), hypertension (69%), cardiovascular disease (3.4%), and diabetes (42%) when compared to agricultural workers in the United States (9.41%, 26%, 2.54%, and 6.74, respectively) .Citation6
Limitations
This study was limited by the difficulty in establishing accurate occupational exposure through the evaluation of electronic medical records and not through an exposure assessment or interviews. In addition, the classification of patients as “agricultural workers” is based on self-report, and although HRSA defines the criteria for this classification, information regarding those criteria is not recorded or reported. Another limitation of this study was that although the geographical area of this study has a high agricultural activity, subject proximity to farms and exposure to farm activities was not evaluated, nor was agricultural worker type (i.e., pesticide applicator or produce collector) assessed. Furthermore, a selection bias may be possible given the nature of the sample population selection method.
Finally, this cross-sectional study was an exploratory analysis with the goal of providing new information regarding the health status of agricultural workers in rural Puerto Rico. Although data quality and availability reduced the scope of the analysis and sample, it is recommended to carry out additional research that targets high prevalence conditions and those diseases presenting a higher risk to farmworkers. Specifically, cohort studies that include occupational surveys and measures of exposure should be conducted to establish a direct association between exposure and health effects.
Conclusions
Agricultural activity in Puerto Rico is constantly highlighted as one of the industries with the potential for recovery and development .Citation19 The economic situation and the impact of recent atmospheric events, as well as the climate crisis, brought to public discussion the need to promote sustainability and food security for the population. In addition, the industry’s growth in recent years has resulted in governmental projects aimed at encouraging and promoting agricultural production. Additionally, the recovery efforts that took place after Hurricane Maria have presented financial opportunities to restore this industry. However, none of these efforts and related policies take into consideration this industry’s worker population.
The lack of information is limiting when developing initiatives that increase the productivity of human resources, as well as providing the framework for worker protection and accessibility to health services. Therefore, it is important to carry out research that produces the necessary information to develop an appropriate framework to protect Puerto Rican farmers while promoting the development of the agricultural industry on the island. Moreover, gathering information about the health characteristics of farmworkers is important when identifying the adequacy and limitations of current policies, standards, regulations, and surveillance programs.
Agricultural workers are exposed to several hazards, including pesticides, high temperatures, and repetitive and heavy load movements. In addition, social demographic and economic characteristics and usual work conditions could make this population even more vulnerable and susceptible to illness and chronic conditions. There are limited data when assessing work-related disease in agricultural workers; in some cases, this limitation is related to health coverage and services of farmers or exceptions regarding reporting for some farming activities .Citation12 Community healthcare facilities that do not require health insurance to provide service to patients, such as HGC, could help address this issue.
Acknowledgments
We thank Hospital General Castañer, Inc. for agreeing to provide access to the data and Guillermo Jimenez, Finances Director, Hospital General Castañer and Robin Russell, Associate Director, Hospital General Castañer for the assistance with electronic medical records that provided the information necessary to carry out the research.
Disclosure statement
There are no financial conflicts of interest to disclose.
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