Community health worker outreach to farmworkers in rural North Carolina: Learning from adaptations to the SARS-CoV-2 pandemic.

BACKGROUND: Community health workers represent a critical part of the health outreach and services for migrant and seasonal farmworkers ('farmworkers') in rural areas of the United States. PURPOSE: We sought to identify adaptations to farmworker patient engagement and health outreach made by community health workers during the first 18 months of the COVID-19 pandemic. METHODS: In this qualitative study, we used semi-structured interviews with community health workers from August 2020 to February 2022 (n = 21). Two coders used thematic analysis to identify three themes related to the experiences of community health workers in conducting health education and outreach to farmworkers prior to and following the onset of the pandemic. FINDINGS: We found themes related to pre-pandemic outreach efforts to provide health education resource sharing with farmworkers and pandemic-related outreach efforts that included adoption of porch drops and distanced delivery of health education, adaptation of modes of health education and communication through technology and the internet, and taking on new roles related to COVID-19. Finally, we identified changes that reverted after the pandemic or will continue as adaptations. CONCLUSIONS: Community health workers created practice-based innovations in outreach in response to the COVID-19 pandemic. These innovations included new COVID-19 related roles and new modes of health education and outreach, including the use of digital resources. The changes developed for emergency use in COVID-19, particularly related to internet and technology, have likely altered how community health workers conduct outreach in North Carolina going forward. Funders, community health worker training programs, and researchers should take note of these innovations. PATIENT OR PUBLIC CONTRIBUTION: Community health workers who typically come from patient populations and provide critical navigation and connection with the health care system advised on the design and creation of this research project, including serving on an advisory board. Two authors have experience working as community health workers.

Exploring the learning preferences of farmworker-serving community health workers.

Community health workers are responsible for finding, processing, and transferring health information to communities with limited access to health-related resources, including farmworkers. This paper is the culmination of an undergraduate student research project to explore the learning processes and preferences of farmworker-serving community health workers in the USA. The project was designed for students from farmworker or agricultural backgrounds at two North Carolina universities and was supported by a North Carolina Department of Health and Human Services workforce development grant. Semi-structured interviews were conducted, in person and virtually, with a convenience sample of 17 current and former community health workers. The interview data were analysed thematically and identified a preference for a combination of learning styles, with visual and hands-on learning being the most preferred. Community health workers also identified the importance of learning preferences in relation to their responsibilities as health educators. This study provides librarians, along with public health and medical professionals, with useful information about learning preferences to inform the creation of new and varied learning materials for community health workers.

"Valorar el trabajo de farmworkers": A thematic analysis of input from farmworkers, advocates, and students in a community documentary project about the future of farm work.

Farm work is one of the nation's most hazardous occupations, and migrant and seasonal farmworkers face significant health inequities. Awareness and understanding of the needs of this population are crucial in assuring they receive appropriate support. Documentary programs can raise awareness of community member views to better inform services and advocacy efforts. Visions for the future of farm work were collected from farmworkers and persons supporting them through a community-based, participatory documentary project led by Student Action with Farmworkers (SAF) from 2021 to 2022. Seventy-nine submissions from participants in North and South Carolina, including text responses and file uploads, were collected and thematically analyzed. Five themes were identified: (1) employment benefits and conditions, (2) living conditions, (3) health access and quality, (4) dignity and visibility of farm work, and (5) policy change for a better future. The visions for the future of farm work expressed by these agricultural workers, advocates, and students raise important implications for agricultural communities, public health practitioners, researchers, funders, and policymakers. Application of these findings in the development and delivery of public health services for farmworkers has the potential to positively impact the morbidity and mortality rates of this at-risk population.

Educator beliefs and organizational constraints: Factors that influence informal education about fish consumption advisories in a southeastern US state.

All US states, and many countries around the world, have waterways with environmental health advisories intended to protect individuals from harmful chemicals in fish, yet little is known about how informal science educators, even those who engage anglers along waterways, incorporate advisory information into their educational activities. This study, grounded in environmental health literacy, investigated the practices, knowledge, and beliefs of 24 informal educators housed in varied agencies and organizations in a southeastern US state. Participants described a range of educational activities and identified organizational constraints on their education about fish consumption advisories, which varied by organization type. Their knowledge of relevant environmental health concepts was incomplete, and they described health and teaching beliefs consistent with limited focus on advisory education. Local government and nonprofit educators were well positioned to educate anglers about advisories, due to their freedom to design and deliver instruction and their regular contact with anglers. Educators in wildlife agencies had more contact with anglers and were identified as potential conduits given their interactions, but organizational constraints (such as educators' ability to choose content/pedagogy and conflicting missions of agencies) would need to be addressed.

Increasing health facility childbirth in Ghana: the role of network and community norms.

BACKGROUND: Reducing pregnancy-related deaths in Sub-Saharan Africa through increases in health facility births may be achieved by promoting community norms and network norms favoring health facility births. However, the process of how both norms shift attitudes and actions towards facility delivery is little studied. We examined the association of network and community norms with facility birth, following a quality improvement intervention to improve facility births in Ghana. METHODS: A 2015 mixed methods evaluation of a Maternal and Newborn Health Referral (MNHR) project in Ghana included a cross-sectional survey of women (N = 508), aged 15-49 years; in-depth interviews (IDIs) with mothers (n = 40), husbands (n = 20) and healthcare improvement collaborative leaders (n = 8); and focus group discussions (FGDs) with mothers-in-law (n = 4) and collaborative members (n = 7). Multivariable logistic regression was used to examine the association of network and community norms with facility birth. Thematic analysis of the qualitative data was conducted to explain this relationship. RESULTS: The network norm of perceived family approval of facility delivery (AOR: 5.54, CI: 1.65-18.57) and the community norm of perceived number of women in the community that deliver in a facility (AOR: 3.00, CI: 1.66-5.43) were independently associated with facility delivery. In qualitative IDIs and FGDs both norms were also collectively perceived as influencing facility delivery. However, network norms were more influential in women's utilization of facility-based pregnancy-related care. Healthcare improvement collaboratives were important in swaying both network and community norms toward facility-based delivery by offering pregnancy-related health information, antenatal care, and support for facility delivery. CONCLUSION: Quality improvement initiatives impact both community and network norms. To be most impactful in advancing facility-based pregnancy-related care, these initiatives should focus on highlighting the shifting trend toward facility delivery in rural communicates and promoting support for facility delivery among women's personal networks.

The Cost of Diversity: An Analysis of Representation and Cost Barriers in Stock Photo Libraries for Health Education Materials, 2021.

INTRODUCTION: Ineffective health communication can drive health disparities and limit the effectiveness of interventions to reduce them. Stock photo libraries are a critical tool for developers of patient education, health education, and intervention materials. It is not clear how well stock photo libraries represent communities bearing disproportionate burdens of disease. METHOD: We conducted a search using five popular stock image libraries (Adobe Stock Images, Canva, Getty Images, Microsoft Office Image Library, and Pixabay) in November 2021 to evaluate diversity and representation in health-related stock photos. We searched for the following five key preventive health topics: healthy eating, exercising, quitting smoking, vaccination, and pregnancy. The images (N = 495) were coded for age, gender presentation, representation of perceived minoritized racial/ethnic identity, skin color using the Massey-Martin skin color scale, markers of high socioeconomic status (SES), and access costs. Results. The representation of perceived minoritized people, darker skin color, and inclusion of markers of high SES varied greatly by the search term and library. Images predominately portrayed young adults and adults, with limited representation of other age groups. Images in libraries with any paywall were significantly more likely to depict a person of perceived minoritized racial/ethnic identity and depict darker skin colors, and were significantly less likely to contain markers of high SES identity than images in libraries that were free to use. DISCUSSION: We found that it costs more to develop culturally relevant health education materials for minoritized populations and groups that do not represent high SES populations. This may hinder the development of effective communication interventions.

An Analysis of the Availability of Health Education Materials for Migrant and Seasonal Farmworkers.

Community health workers (CHWs) have reported a paucity of farmworker-specific education materials for use during health outreach to farmworkers. To improve our understanding of the availability of topically and culturally relevant health education materials for farmworkers, we identified 15 key health topics to examine across four major online health information services: MedlinePlus.gov, Migrant Clinicians Network, National Agricultural Safety Database, and National Center for Farmworker Health. We established inter-coder reliability and conducted coding for health education materials by topic and identified the percentage of materials specifically designed for farmworkers. The availability of materials ranged from, on the low end, accessing clinic services, having one health education material total across all four online services, to alcohol, tobacco, and other drugs, having 50 materials across the four online services. Online health information services ranged from 0.6% of the materials designed specifically for farmworkers (MedlinePlus.gov) to 42.9% (Migrant Clinicians Network). The findings from this study underscore the need to support community-based projects centering CHWs' roles as advocates and facilitators to develop educational materials for farmworker health outreach.

Focus groups revealed how community health workers in North Carolina find, verify, and process health information for migrant and seasonal farmworkers.

BACKGROUND: Community health workers (CHWs) bridge the gap in health and social services delivery for marginalized communities, providing critical health information to those with limited access to health resources. OBJECTIVES: The purpose of our study was to understand CHWs' approaches to identifying salient and credible health information for migrant and seasonal farmworkers in rural North Carolina (NC). METHODS: Two focus group discussions were held with CHWs in eastern NC and one in western NC in February 2020. RESULTS: CHWs seek health information on chronic health conditions disproportionately experienced by farmworkers such as diabetes and high blood pressure. They search for information from existing resources in their possession, via the internet, and through consultation with health professionals. CHWs also verify the information and transform the content into resources that are accessible to farmworkers. DISCUSSION: Our findings suggest that CHWs possess a strong set of information literacy skills that could be enhanced through additional training in crediting sources, creating new materials, and organization and storage. CONCLUSION: This study adds to the very limited body of knowledge about how CHWs seek and transmit information to their communities and sheds light on their information need and literacy abilities.

Community Health Workers' Role in Addressing Farmworker Health Disparities.

Community health workers (CHWs) are uniquely positioned to connect migrant and seasonal farmworkers to health promotion and clinical services. However, research on CHWs' experiences, particularly related to their provision of health education to farmworkers, is limited. To explore CHWs' practices and challenges in conducting health education outreach, we conducted three focus group discussions with farmworker health CHWs (N = 28) in North Carolina in the spring of 2020. We analyzed the focus group transcripts, and we compared the code outputs, thematic code summaries, and memos maintained throughout the analytic process to examine the experiences of CHWs in acquiring and disseminating health information and resources, including use of technology. We identified three themes related to CHWs' experiences providing health information to farmworkers. First, CHWs described short-term preparation, immediately before providing health outreach, and long-term activities, devoted to maintaining and improving their capacity to provide relevant health information to farmworkers. Second, they described their use of health education delivery methods, including open-ended questions, participatory and interactive approaches, and non-verbal aids. Third, participants described their current use of technology and related challenges, as well as the technology needed to enhance health outreach, including internet access. Findings reveal opportunities to improve farmworker health education through professional development for CHWs, identification of preferred methods of health education delivery to farmworkers, and provision of technology to farmworker-serving organizations. Establishing rural internet access and equipping outreach organizations with technology would position CHWs to be maximally effective as they strive to reduce farmworkers' health inequities.Abbreviations: CHW: Community health worker; FGD: focus group discussion; NC: North Carolina.

Creating information resources and trainings for farmworker-serving community health workers.

BACKGROUND: Farmworker-serving community health workers have limited access to farmworker health research findings, training, and education resources. With funding from the National Library of Medicine, we are working to improve the health information literacy of both community health workers and farmworkers. We conducted focus group discussions with community health workers to explore their experiences providing health education and information to farmworkers, their information-seeking behaviors, and their technology and information needs. Data from the focus groups provided insights into the main areas in which community health workers would like to receive professional development. CASE PRESENTATION: Our team, which includes health sciences librarians, developed a resource list of educational materials for farmworker health, videos to increase community health workers' skills finding health information online, and webinars to introduce these resources to community health workers. Videos, available in Spanish and English, included instruction on finding and evaluating online health information, accessing reputable online consumer health information sources, and advanced searching tips for Google and PubMed. Through three webinars, we introduced the resource list, videos, and design software for creating handouts and infographics to community health workers. CONCLUSIONS: Community health workers have a critical role in providing health education and information to farmworkers, and our efforts represent a first step in addressing community health workers' limited access to professional development. Health sciences librarians are well positioned to partner with interdisciplinary teams working to reduce health disparities and provide resources and training to community health workers, farmworkers, and other underserved communities.

Advancing the Health of Migrant and Seasonal Farmworkers in the United States: Identifying Gaps in the Existing Literature, 2021.

There are profound health inequities for agricultural workers. We sought to assess the literature on migrant and seasonal farmworker health with an eye toward health promotion interventions, special populations, use of community health workers (CHWs), and technology. We conducted a systematic mapping review by searching five databases in March 2021. Using quantitative content analysis after establishing interrater reliability, we coded titles and abstracts to assess 13 topics and six characteristics of the research such as its focus on health promotion, use of technology, and inclusion of CHWs. We identified 1,083 records. Just 8.2% of records described or evaluated a health promotion effort to intervene in farmworker well-being and even fewer (4.2%) examined unique populations of farmworkers such as indigenous farmworkers (n = 11) or sexual minority farmworkers (n = 1). A small body of literature focused on the role of CHWs or promotores most frequently described their role in implementing health interventions. The literature on farmworker health has gaps regarding health promotion interventions, special populations, and integration of CHWs into research projects. We offer suggestions to fill in identified gaps in the literature.

A Comparison of Pesticide Risk Beliefs between Farmers and Farmworkers: Implications for Risk Communication and Education.

Understanding the multi-dimensional risk beliefs of agricultural audiences allows risk communicators and educators to target those beliefs to improve practices. This study was designed to assess pesticide risk beliefs among English-speaking farmers and Spanish-speaking farmworkers and to compare their beliefs. The Pesticide Risk Beliefs Inventory (PRiBI) is a 19-item quantitative instrument used to assess the alignment of risk beliefs with those beliefs of experts in the field. A higher score on the PRiBI relates to an agreement with expert beliefs regarding pesticide risk. Farmers' and farmworkers' scores were signficiantly different on items corresponding to the use of physical properties to determine risk and specific adverse health outcomes associated with pesticide exposure. With an understanding that farmworkers rely on the physical properties of pesticides to assess risk, educators and farmers can encourage more reliable ways to assess pesticide hazards.

Coronavirus pandemic highlights critical gaps in rural Internet access for migrant and seasonal farmworkers: a call for partnership with medical libraries.

Migrant and seasonal farmworkers, who are essential workers in the coronavirus global public health emergency, face unique risks to their health as well as longstanding health inequities. This commentary highlights these risks and argues that Internet access represents an underappreciated but critical part of the public health response. The authors first discuss the unique risks farmworkers face. We note the importance of Internet access in the time of physical distancing, the fact that many health outreach workers are no longer visiting camps, the need for telemedicine infrastructure, and the role of Internet access in providing connections to families in communities of origin. We describe existing efforts that have been implemented in North Carolina to raise awareness among public health and health promotion practitioners and researchers. The current coronavirus pandemic demands the attention of medical libraries, public health practitioners, and policy makers to address the digital divide for farmworkers and their families.

Anglers' Views on Using Signs to Communicate Fish Consumption Advisories.

The purpose of this case study was to examine signs as a means of communicating fish consumption advisory information to English- and Spanish-speaking anglers in North Carolina. This study involved a group of stakeholders, including representatives from local and state agencies, non-governmental organizations, and academia, as well as 38 anglers in focus group discussions to learn about their knowledge and beliefs in the context of fishing in polluted waterways, including what they knew about fish consumption advisories and their perceptions of prototype signs. Across groups, participants identified two confusing elements of signs: the allowable number of servings of fish under advisory and distinct consumption recommendations for different subgroups. They recommended streamlined messaging and the use of visuals, lay terms, and locally relevant languages as ways to improve prototype signs. Additionally, participants identified the state wildlife agency as a common source of information about fish safety, more so than signs. These results suggest opportunities for improved communication of advisories, especially to the most at-risk populations.

Certified Safe Farm Implementation in North Carolina: Hazards, Safety Improvements, and Economic Incentives.

OBJECTIVES: Certified Safe Farm (CSF) is a multimodal intervention composed of four components: safety, health, education, and economic incentive. North Carolina has conducted the largest implementation of CSF outside of the Midwestern United States where it was developed. This paper describes the Efficacy dimension of the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework for the implementation of CSF in North Carolina during 2009-2012 on 113 farms in a three-county, highly productive and diverse agricultural area. METHODS: Using descriptive statistics, analysis of variance, correlational analyses, and logistic regression, quantitative data were examined from on-farm safety reviews, as well as primary operators' use of cost-share funds as an economic incentive (34% participation) to make identified safety and health improvements on the farm. RESULTS: Overall farm safety review scores were generally high (96% passing rate). Category scores revealed hazards in seven key categories: Chemical Storage; Tractors; Machine Shop, Repair Area; Gravity Flow, Auger, and Forage Wagons; Portable Augers; Dairy and Beef Structures; and Swine and Poultry Structures. The cost-share economic incentive component was utilized in addressing hazards in five of these categories, as well as in nine others. The average per farm cost-share reimbursement was $3,276, with a median of $1,615. In total, an investment of $255,307 (farmer investment plus incentive) was made in safety and health improvements on farms (n = 38). Correlation and logistic regression analyses revealed no significant relationships among scores, cost-share investments, and selected farm demographics. CONCLUSION: Findings suggest the 50% cost-share for safety and health improvements is a promising economic incentive model for CSF implementation.

Selenium, Mercury, and Their Molar Ratio in Sportfish from Drinking Water Reservoirs.

Mercury (Hg) bioaccumulates in aquatic ecosystems and may pose a risk to humans who consume fish. Selenium (Se) has the ability to reduce Hg toxicity, but the current guidance for human consumption of fish is based on Hg concentration alone. The purpose of the present study was to examine the relationship between Se and Hg in freshwater sportfish, for which there is a paucity of existing data. We collected three species of fish from different trophic positions from two drinking water reservoirs in central North Carolina, USA, to assess Hg and Se concentrations in relation to fish total length and to compare two measures of the protective ability of Se, the Se:Hg molar ratio and Se health benefit value (HBVSe), to current guidance for Hg. According to the Se:Hg molar ratio, all of the low trophic position fish sampled and the middle trophic position fish sampled from one of the reservoirs were safe for consumption. The same number of fish were considered safe using the HBVSe. More fish were deemed unsafe when using the Se:Hg molar ratio and HBVSe than were considered unsafe when using the U.S. Environmental Protection Agency (USEPA) Hg threshold. These findings suggest that the measures of Se protection may be unnecessarily conservative or that the USEPA Hg threshold may not be sufficiently protective of human health, especially the health of sensitive populations like pregnant or nursing mothers and young children. Future examination of the Se:Hg molar ratio and HBVSe from a variety of fish tissue samples would help refine the accuracy of these measures so that they may be appropriately utilized in ecological and human health risk assessment.

Engaging outreach workers in the development of a farmworker health research agenda.

Farmworker health outreach workers have not traditionally been involved in the prioritization and design of research studies. This report from the field shares the results of a survey administered to outreach workers providing health services to farmworkers in North Carolina. Priority areas of research and best practices for engaged research are presented from the perspective of the outreach worker community. The purposeful involvement of outreach workers can make farmworker health research more meaningful and solution-oriented.

A Retrospective Analysis of Agricultural Herbicides in Surface Water Reveals Risk Plausibility for Declines in Submerged Aquatic Vegetation.

The Albemarle-Pamlico Estuarine System (APES) is the second largest estuarine system within the mainland of the United States and is estimated to have lost about half of its submerged aquatic vegetation (SAV) over the past several decades. The issue of herbicide runoff and subsequent toxic effects to SAV is important because of the extensive agricultural production that occurs in the APES region. The aim of this study was to conduct a retrospective analysis of herbicide influx to waters of the APES region during the time period of documented SAV declines and to compare the measured concentrations to SAV toxicity thresholds and changes in agricultural land use. Surface water grab samples were collected at 26 sites in the APES region during May through July 2000. The most consistently measured herbicides were alachlor, atrazine, and metolachlor with geometric mean concentrations ranging from 29 to 2463 ng/L for alachlor, 14 to 7171 ng/L for atrazine, and 17 to 5866 ng/L for metolachlor. Concentrations of alachlor, atrazine, and metolachlor measured in water samples from the APES region in 2000 exceeded several of the established benchmarks, standards, or guidelines for protection of aquatic plants. Although this evaluation was of point-in-time herbicide samples (year 2000) and not analyzed for all possible herbicides used at the time, they were taken during the period of SAV declines, reveal the plausibility of exposure risk to SAV, and suggest that herbicide runoff should be studied along with other variables that influence SAV growth and distribution in future studies.

Benefits, Facilitators, Barriers, and Strategies to Improve Pesticide Protective Behaviors: Insights from Farmworkers in North Carolina Tobacco Fields.

Pesticide exposure is associated with deleterious health effects. Prior studies suggest Latino farmworkers perceive little control over their occupational health. Using the Health Belief Model as a theoretical guide, we explored the perceptions of Latino farmworkers working in tobacco in North Carolina (n = 72) about benefits and facilitators of pesticide protective behaviors as well as barriers, and strategies to overcome barriers to their use. Interviews were conducted with participants at farmworker housing during non-work time. Qualitative data were analyzed using ATLAS.ti. Farmworkers recognized pesticide protective behaviors as helping them to not get sick and stay healthy. Farmworkers perceived work experience as facilitating protective behaviors. Wetness in the field was the most commonly cited barrier to protective behavior use. To overcome this barrier, farmworkers suggested use of water-resistant outerwear, as well as packing a change of clothes for mid-day, with space and time to change provided by employers. Examination of the efficacy and feasibility of farmworkers' suggestions for addressing barriers is warranted. Training and behavior modeling by experienced peers may improve behavior adoption and perceived control.