Developing a National-Scale Exposure Index for Combined Environmental Hazards and Social Stressors and Applications to the Environmental Influences on Child Health Outcomes (ECHO) Cohort.

Tools for assessing multiple exposures across several domains (e.g., physical, chemical, and social) are of growing importance in social and environmental epidemiology because of their value in uncovering disparities and their impact on health outcomes. Here we describe work done within the Environmental influences on Child Health Outcomes (ECHO)-wide Cohort Study to build a combined exposure index. Our index considered both environmental hazards and social stressors simultaneously with national coverage for a 10-year period. Our goal was to build this index and demonstrate its utility for assessing differences in exposure for pregnancies enrolled in the ECHO-wide Cohort Study. Our unitless combined exposure index, which collapses census-tract level data into a single relative measure of exposure ranging from 0-1 (where higher values indicate higher exposure to hazards), includes indicators for major air pollutants and air toxics, features of the built environment, traffic exposures, and social determinants of health (e.g., lower educational attainment) drawn from existing data sources. We observed temporal and geographic variations in index values, with exposures being highest among participants living in the West and Northeast regions. Pregnant people who identified as Black or Hispanic (of any race) were at higher risk of living in a "high" exposure census tract (defined as an index value above 0.5) relative to those who identified as White or non-Hispanic. Index values were also higher for pregnant people with lower educational attainment. Several recommendations follow from our work, including that environmental and social stressor datasets with higher spatial and temporal resolutions are needed to ensure index-based tools fully capture the total environmental context.

Structural Competency and Agricultural Health and Safety: An Opportunity to Foster Equity within Agriculture.

The future of agricultural work in the United States (U.S.) must account for at least two important trends: 1) the persistence of the industry being riddled with high rates of injury and illness and 2) the growing proportion of hired farmworkers compared to family farmworkers working in these dangerous environments. These workers confront structural disadvantages that impede social justice and prosperity. Social structures like policies, economic systems, institutions, and social hierarchies create health disparities, often along the lines of social categories. The result is an already dangerous industry with vulnerable workers facing unjust risks, especially those that are undocumented. Agricultural health and safety professionals and other stakeholders should engage structural competency curricula in order to increase awareness of impact of structures and be better positioned to improve farmworker health and wellbeing. Similar work has been successful in the training healthcare professionals, e.g. the Structural Competency Working Group (SCWG). New strategies are needed to improve farmworker wellbeing and retain an adequate agricultural workforce. A greater understanding of the social and structural concerns that farmworkers face is an important step towards occupational and social justice. It is also clear that it will require collaboration and community-based efforts creating a larger team of people using similar concepts related to the structural influences on whether health and wellbeing are distributed equitably. This work is being moved forward in healthcare, social work, worker organizations, and community-based initiatives. Agricultural health and safety professionals have a vital contribution to make if they join the ranks.

Health Care and Health Insurance Access for Farm Families in the United States during COVID-19: Essential Workers without Essential Resources?

In the midst of the COVID-19 pandemic, farmers and farm workers have been deemed essential workers across the world. Yet, despite working in one of the most dangerous occupations, and despite being especially vulnerable to the virus (due to existing health risk factors and risk of infection stemming from difficulties adopting control measures), many farmers and farm workers in the United States have long lacked essential resources to ensure they can meet their health needs: affordable and accessible health insurance and health care. In this commentary, we draw on our own research focused on farm families and collective experiences to discuss three main challenges farm families have faced meeting their health needs: reliance on off-farm work for health insurance coverage, the need to forecast income when purchasing a plan on the health insurance marketplace, and barriers to health care in rural areas. As we discuss these challenges, we highlight the ways in which the COVID-19 pandemic is likely exacerbating these pressures. Recognizing that major crises in the past have led to major shifts in economic, social, and political systems, the disruptions brought on by COVID-19 could be leveraged to work toward increasing access to affordable and adequate health insurance and health care. As such, we conclude our commentary by outlining policy reforms and research efforts that are needed to ensure that those working in the farm sector have access to essential resources to preserve their health and safety.

A Model for Assessing Necessary Conditions for Rural Health Care's Mobile Health Readiness: Qualitative Assessment of Clinician-Perceived Barriers.

BACKGROUND: Mobile health (mHealth) technology dissemination has penetrated rural and urban areas alike. Yet, health care organization oversight and clinician adoption have not kept pace with patient use. mHealth could have a unique impact on health and quality of life for rural populations. If organizations are prepared to manage mHealth, clinicians may improve the quality of care for their patients, both rural and urban. However, many organizations are not yet prepared to prescribe or prohibit third-party mHealth technologies. OBJECTIVE: This study explored organizational readiness for rural mHealth adoption, the use of patient-reported data by clinical care teams, and potential impact on improving rural health care delivery. METHODS: Semistructured, open-ended interviews were used to investigate clinicians' current practices, motivators, and perceived barriers to their use of mHealth technologies in rural settings. RESULTS: A total of 13 clinicians were interviewed, and 53.8% (7/13) reported encouraging use of mHealth apps or wearable devices with rural patients. Perceived barriers to adoption were categorized into three primary themes: (1) personal (clinician), (2) patient, and (3) organizational. Organizational was most prominent, with subcodes of time, uniformity, and policy or direction. Thematic analysis revealed code-category linkages that identify the complex nature of a rural health care organization's current climate from a clinician's perspective. A thematic map was developed to visualize the flow from category to code. Identified linkages guided the development of a refined rural mHealth readiness model. CONCLUSIONS: Clinicians (including physicians) have limited time for continuing education, research, or exploration of emerging technologies. Clinicians are motivated to learn more, but they need guidance through organization-led directives. Rural health care institutions should consider investing in mHealth analysis, tool development, and formal recommendations of sanctioned tools for clinicians to use with patients.

An Argument Against Cross-Platform Development: Lessons From an Augmented Reality App Prototype for Rural Emergency Responders.

BACKGROUND: Mobile augmented reality (MAR) apps offer potential support for emergency responders in rural areas. OBJECTIVE: In this report, we described lessons learned from the development process of augmented reality (AR) Farm Mapping to Assist, Protect and Prepare Emergency Responders (MAPPER), a MAR app that provides emergency responders onsite information about the agricultural operation they enter. METHODS: Cross-platform frameworks were used to create AR MAPPER to accommodate budget constraints and overcome issues with markerless MAR technologies. Although the single codebase and Web technologies streamlined development, cross-device hardware limitations impacted location accuracy, lengthened the development cycle, and required regular updates to third-party libraries. RESULTS: A hybrid development approach of using Web-based technologies with native tie-ins for specialized components and enhanced performance cut time and costs. This also led to consistency across multiple platforms and ensured that there is only a single set of source files to modify for Android and iPhone operating systems. Meanwhile, active development was delayed by some major hurdles. Apple and Google both released new versions of their operating systems, and the Wikitude framework issued four major updates, each of which brought with it some important enhancements and also led to some new issues. CONCLUSIONS: Developers should consider single platform native development to benefit from platform-specific MAR implementations and to avoid development, testing, and maintenance costs associated with cross-platform implementation. Emergency response organizations may be more likely to utilize a single platform across the devices used by their command staff. This also reduces the benefits of cross-platform development. Furthermore, providing map-based, non-AR cross-platform apps for landowners, farmers, and ranchers would help improve and maintain data quality, which is crucial for the utility and user experience of MAR apps.

Sorting Through the Spheres of Influence: Using Modified Pile Sorting to Describe Who Influences Dairy Farmers' Decision-Making About Safety.

OBJECTIVES: The primary goal of this study was to describe the mutually perceived influence of bankers and insurers on their agricultural clients' decision-making regarding health and safety. METHODS: Semistructured interviews were conducted with 10 dairy farmers, 11 agricultural bankers, and 10 agricultural insurers from central Wisconsin. Three of the interview questions involved pile sorting. Pile sorting included 5-point Likert-like scales to help participants sort through 32 index cards. Each card represented an individual or group that was thought to possibly affect farmers' decision-making, both generally and about health and safety. Results (photographs of piles of cards quantified into spread sheets, fieldnotes, and interview transcripts) were analyzed with SAS and NVivo. RESULTS: All three groups expressed moderate-to-strong positive opinions about involving agricultural bankers (x2(2) = 2.8155, p = 0.2695), although bankers qualitatively expressed apprehension due to regulations on the industry. Insurance agents received more positive support, particularly from bankers but also from dairy farmers themselves, and expressed more confidence in being involved in designing and implementing a farm safety program. CONCLUSION: Agricultural bankers and insurers can influence individual farmer's decision-making about health and safety. Both are believed to be good purveyors of safety programs and knowledge, especially when leveraging financial incentives. Insurance agents are thought to be more critical in the design of safety programs. Insurers and bankers being financially tied to safety programs may prove both positive and negative, as farmers may be skeptical about the intention of the incentives, making messaging critical.

"When This Breaks Down, It's Black Gold": Race and Gender in Agricultural Health and Safety.

Farmers are growing older, and fewer new agriculturists are rising to take their place. Concurrently, women and minorities are entering agriculture at an increasing rate. These rates are particularly curious viewed in light of the racialized and gendered nature of agriculture. Slavery and agriculture share strong historical roots, with many male slaves performing agricultural labor. So then, why would African American women choose to engage in agriculture in any form? Participant observation and in-depth interviews with a group of African American women urban farmers in the southeastern United States were asked this question. Interviews with seven such women revealed their perception of self-sustainable small-scale agriculture as a departure from, not return to, slavery. The women drew metaphors between the Earth and femininity, believing their work to be uniquely feminine. Production of food for consumption and trade provides a source for community and healthy food amid urban poverty and the plight of food deserts. These data encourage agricultural health and safety professionals and researchers to tackle the health-promoting nature of such work, with the entrée of anthropology and other social sciences into the field. In many ways, these women portrayed small-scale food cultivation as an important component of, rather than a threat to, health and safety. Indeed, they viewed such labor as wholly health promoting. Their strong social connections provide a potential means for community-led dissemination of any relevant health and safety information.