Amy K. Liebman

Promoting integrated approaches to reducing health inequities among low-income workers: Applying a social ecological framework

BACKGROUND Nearly one of every three workers in the United States is low-income. Low-income populations have a lower life expectancy and greater rates of chronic diseases compared to those with higher incomes. Low- income workers face hazards in their workplaces as well as in their communities. Developing integrated public health programs that address these combined health hazards, especially the interaction of occupational and non-occupational risk factors, can promote greater health equity. METHODS We apply a social-ecological perspective in considering ways to improve the health of the low-income working population through integrated health protection and health promotion programs initiated in four different settings: the worksite, state and local health departments, community health centers, and community-based organizations. RESULTS Examples of successful approaches to developing integrated programs are presented in each of these settings. These examples illustrate several complementary venues for public health programs that consider the complex interplay between work-related and non work-related factors, that integrate health protection with health promotion and that are delivered at multiple levels to improve health for low-income workers. CONCLUSIONS Whether at the workplace or in the community, employers, workers, labor and community advocates, in partnership with public health practitioners, can deliver comprehensive and integrated health protection and health promotion programs. Recommendations for improved research, training, and coordination among health departments, health practitioners, worksites and community organizations are proposed.

A pilot program using promotoras de salud to educate farmworker families about the risk from pesticide exposure.

Abstract This paper reviews a successful community-based education effort to minimize pesticide exposure to migrant and seasonal farmworkers and their families through innovative training curricula, informal participatory educational techniques and culturally sensitive outreach methods. In 2004, Migrant Clinicians Network, Inc., trained lay health educators, or promotoras de salud, from local agencies in southern New Mexico in pesticide safety and in ways to successfully promote safety information in the farmworker community. Through home visits and small group workshops, the promotoras trained 273 farmworkers and farmworker family members on ways to reduce exposures to pesticides in their homes and at work, with an emphasis on protecting children. The families received a Spanish language comic book that reinforced the pesticide safety information, emphasizing the health effects of acute and chronic pesticide exposure and steps to protect farmworker children from pesticide exposure. The project resulted in a significant increase in knowledge regarding the routes of exposure, the vulnerability of children, the signs and symptoms of pesticide poisonings and the ways to minimize pesticide exposures. Additionally, the project showed improved behaviors aimed at minimizing pesticide exposure through accidental poisonings in the home. This pilot project proved the efficacy of an in-home, one-on-one approach with a culturally appropriate educational comic book as an instrument to help transfer education to the community. Moreover, the educational method involving promotoras offers a training-of-trainer approach that is easy to implement and potentially replicate.

Effects of Social, Economic, and Labor Policies on Occupational Health Disparities

BACKGROUND This article introduces some key labor, economic, and social policies that historically and currently impact occupational health disparities in the United States. METHODS We conducted a broad review of the peer-reviewed and gray literature on the effects of social, economic, and labor policies on occupational health disparities. RESULTS Many populations such as tipped workers, public employees, immigrant workers, and misclassified workers are not protected by current laws and policies, including workers compensation or Occupational Safety and Health Administration enforcement of standards. Local and state initiatives, such as living wage laws and community benefit agreements, as well as multiagency law enforcement contribute to reducing occupational health disparities. CONCLUSIONS There is a need to build coalitions and collaborations to command the resources necessary to identify, and then reduce and eliminate occupational disparities by establishing healthy, safe, and just work for all.

Unique Agricultural Safety and Health Issues of Migrant and Immigrant Children

ABSTRACT Immigrant and migrant youth who live and work in agricultural settings experience unique agricultural safety and health issues. Mobility, poverty, cultural differences, immigration status, language, education, housing, food security, regulatory standards and enforcement, and access to childcare and health care influence exposure risk and the well-being of this population. Approximately 10% of the migrant agricultural labor force is composed of unaccompanied minors, whose safety and health is further compounded by lack of social supports and additional stresses associated with economic independence. This paper examines the current demographic and health data, regulatory protections, and programs and practices addressing safety and health in this sector of youth in agriculture. Gaps in knowledge and practice are identified, with emphasis on data collection and regulatory limitations. Best practices in programs addressing the special needs of this population are highlighted. Recommendations identify seven priority areas for impact to promote transformative change in the agricultural health and safety concerns of unaccompanied minors and children of immigrant, migrant and seasonal farmworkers. This framework may be used to examine similar needs in other identified subpopulations of children as they merit attention, whether now or in the future.

Health Care Access and Health Care Workforce for Immigrant Workers in the Agriculture, Forestry, and Fisheries Sector in the Southeastern US

BACKGROUND The Agriculture, Forestry, and Fishery (AgFF) Sector workforce in the US is comprised primarily of Latino immigrants. Health care access for these workers is limited and increases health disparities. METHODS This article addresses health care access for immigrant workers in the AgFF Sector, and the workforce providing care to these workers. CONTENTS Immigrant workers bear a disproportionate burden of poverty and ill health and additionally face significant occupational hazards. AgFF laborers largely are uninsured, ineligible for benefits, and unable to afford health services. The new Affordable Care Act will likely not benefit such individuals. Community and Migrant Health Centers (C/MHCs) are the frontline of health care access for immigrant AgFF workers. C/MHCs offer discounted health services that are tailored to meet the special needs of their underserved clientele. C/MHCs struggle, however, with a shortage of primary care providers and staff prepared to treat occupational illness and injury among AgFF workers. A number of programs across the US aim to increase the number of primary care physicians and care givers trained in occupational health at C/MHCs. While such programs are beneficial, substantial action is needed at the national level to strengthen and expand the C/MHC system and to establish widely Medical Home models and Accountable Care Organizations. System-wide policy changes alone have the potential to reduce and eliminate the rampant health disparities experienced by the immigrant workers who sustain the vital Agricultural, Forestry, and Fishery sector in the US.

The Quality of Drinking Water in North Carolina Farmworker Camps

OBJECTIVES The purpose of this study was to assess water quality in migrant farmworker camps in North Carolina and determine associations of water quality with migrant farmworker housing characteristics. METHODS We collected data from 181 farmworker camps in eastern North Carolina during the 2010 agricultural season. Water samples were tested using the Total Coliform Rule (TCR) and housing characteristics were assessed using North Carolina Department of Labor standards. RESULTS A total of 61 (34%) of 181 camps failed the TCR. Total coliform bacteria were found in all 61 camps, with Escherichia coli also being detected in 2. Water quality was not associated with farmworker housing characteristics or with access to registered public water supplies. Multiple official violations of water quality standards had been reported for the registered public water supplies. CONCLUSIONS Water supplied to farmworker camps often does not comply with current standards and poses a great risk to the physical health of farmworkers and surrounding communities. Expansion of water monitoring to more camps and changes to the regulations such as testing during occupancy and stronger enforcement are needed to secure water safety.

Immigrant dairy workers' perceptions of health and safety on the farm in America's Heartland.

BACKGROUND Dairy farming is dangerous. Yearly, farms grow fewer and larger by employing immigrant workers, who have limited industrial agriculture experience and safety and health training. METHODS We examined results of five focus groups with 37 Hispanic, immigrant dairy workers. Analysis followed a grounded theory approach and employed ATLAS.ti. RESULTS Reported injury experience affirmed the hazardous nature of dairy. Some workers received appropriate worker compensation benefits, whereas others were instructed to deny work-relatedness. Some employers covered medical injury costs out-of-pocket, whereas others did not. Cows were a major injury source. Pressure to work and weather were noted as injury risk factors. Worker compensation was poorly understood, and immigration status and fear of deportation influenced injury and hazard reporting. CONCLUSION Injury management practices range from benevolent to threatening. Workers compensation is poorly understood and undocumented status is an occupational hazard. We underscore the need for further research and immigration policy change.

The Migrant Clinicians Network: Connecting Practice to Need and Patients to Care

ABSTRACT Migrant Clinicians Network advocates for migrants and clinicians, develops appropriate resources, engages outside partners, conducts translational research, and runs programs that support clinical care on the front line of migrant health. Migrant Clinicians Networks goal is to improve health care for migrants by providing support, technical assistance, and professional development to clinicians in Federally Qualified Health Centers and other healthcare delivery sites with the ultimate purpose of providing quality health care that increases access and reduces disparities for migrant farmworkers and other mobile underserved populations. In this article the authors examine the migrant population in the United States, a brief history of clinicians working in migrant health, and the scope of current Migrant Clinicians Network activities, including occupational and environmental health.

Developing the 2012 national action plan for protecting children in agriculture

ABSTRACT In 1996 the US launched a National Childhood Agricultural Injury Prevention Initiative, guided by an action plan generated by a 42-member multidisciplinary committee. A major update to the plan was released following the 2001 Summit on Childhood Agricultural Injury Prevention. From the year 2010 through 2011 a comprehensive assessment of progress to date was conducted followed by the drafting, review and finalizing of a new action plan—“The 2012 Blueprint for Protecting Children in Agriculture.” This paper briefly describes the purpose and process for generating the new action plan then provides a listing of the 7 goals and 26 strategies within the plan. These goals and strategies account for trends in childhood agricultural injuries, changes in agricultural production and the demographics of its workforce, effectiveness of interventions, and the increasing use of social media, marketing and social networking. Primary funding for this project was provided by the National Institute for Occupational Safety and Health (NIOSH), which continues to serve as the lead federal agency for the national initiative.

Applying Learning Theory to Safety and Health Training for Hispanic Immigrant Dairy Workers

We designed a safety and health curriculum for dairy immigrant workers aiming to increase knowledge, encourage safe behavior, and reduce worker communication inequalities to prevent occupational injury and diseases. The design is largely based on the Taxonomy of Significant Learning and incorporated behavioral and adult learning theories and principles of occupational hazard control. Trainings were implemented with 836 Spanish-speaking workers from 67 farms in Wisconsin. Sixty-seven percent of workers reported never being trained before in dairy safety, 65% of these worked in dairy for 5 or fewers years, and 26% of workers reported being ever injured while working on dairy. Quantitative and qualitative evaluation of the trainings suggest that our curriculum successfully increased worker knowledge and promoted contemplation of safe practices. The overall knowledge gain of 25% was statistically significant (p < .01). Workers recalled at least one key concept, expressed confidence of adopting at least one safety behavior, and mentioned their intention to communicate safety concerns to farmers. To our knowledge, this is the first Taxonomy of Significant Learning application to occupational safety and health education. Our curriculum can support dairy farmers’ compliance with Occupational Safety and Health Administration’s annual training requirements by providing our basic safety and health training to workers at early job stages.