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Following the discussions about priorities for surveillance and research, the work group addressed project design and methods. As with the two other areas, the study design priorities were ranked in order of importance and organized with a set of categories and sub-categories also ranked in order. As for the methods, the work group suggested several data and document sources that could be useful in the surveillance of hired farm worker safety and occupational health. In making its recommendations, the work group noted both the strengths and weaknesses of each method. For a complete breakdown of the project design priorities and a list of the data and document sources and their limitations, refer to Appendix D.
Under Regional and Local studies, the top three priorities pertain to household surveys, clinic-based projects, and studies that look at health outcomes and their associations with specific exposures. For community oriented household surveys, it is essential that the project design include means for gathering occupational information, enumerate and collect data from farm workers living in unconventional dwellings, and obtain data from ill or injured workers who are not seeking medical care for their problem.
With respect to the migrant health center, clinic-based approach, two important priorities are computerization and developing appropriate case-reporting mechanisms such as clinician reporting to state agencies and follow-up care. Other design priorities involve linking local survey efforts with clinics so that an exam component can be incorporated into the process. Lastly, the diagnoses of local clinics and migrant health care centers need to be compared to population baseline.
For health outcomes and their associations with exposures, determining causation is the first design priority. Second is a comparison between acute and chronic conditions. This can be done through both longitudinal and multi-site studies. A key element in this type of design will involve the identification of a suitable comparison or control group.
Other priorities for regional and local project design involve data collection systems. These methods include the use of NIOSH Agricultural Safety and Health Centers in conjunction with community based farm worker organizations and migrant clinics, the use of lay health workers, promotoras, recruited from the farm worker community, and the use of health fairs that offer free services such as health screenings. All of these approaches serve to improve contact with a population that rarely uses health care services.
The remaining two priorities involve geographic and temporal differences and measuring the extent to which workers' compensation data underestimate the true prevalence of specific conditions such as eye problems. With respect to the former, it is important that all surveillance projects incorporate these differences into their design. Otherwise, the results will fail to accurately represent the health outcomes for the hired farm worker population.
As for Workers' Compensation Insurance, its primary deficiencies stem from a lack of protection for hired farm workers nationwide. Since many states either exempt agricultural employers from having to provide coverage for their workers or only make it mandatory under limited conditions, this system cannot be used to obtain accurate cross-sectional data. However, comparisons can be made between those states that do make coverage mandatory for all agricultural workers and those that do not. Likewise, surveillance projects can examine regional differences between those states that do offer coverage and compare how those variations affect workers' compensation services.
For National and International studies, the highest priority is to obtain national baseline data. The first step is to develop a series of exposure surveys similar to the National Occupational Health Survey (NOHS). In doing so, it is critical that the surveys accurately gather data that is representative of the entire hired farm worker population. This must include the capacity for detecting differences due to climate or geography while being flexible enough to gather information from those farm workers who live in unconventional dwellings.
The next procedure involves correlating the results from exposure surveillance with illness and injury data and determining the relationship between a specific exposure and a specific health outcome. Essential in the identification of illnesses and exposures will be the use of standard survey instruments such as National Health Information Survey (NHIS) and the Hispanic Health and Nutrition Examination Survey (HHANES). This information can be augmented and reinforced with data gathered by lay health workers conducting interviews of hired farm workers.
The second highest priority with respect to national/international studies involves clinic-based research for all categories of hazardous exposures. The design for this approach should include both migrant health centers and occupational clinics, and it should focus on developing appropriate case-reporting mechanisms such as continued follow-up care.
The third priority pertains to health outcomes and their associations with workplace exposures. Here, projects need to examine causation and compare acute and chronic conditions. Methods for addressing this particular issue should involve the use of both longitudinal and multi-site studies.
The remaining priorities for national/international studies pertain to surveys, cross-border surveillance, collaborative efforts between NIOSH Agricultural Safety and Health Centers and community-based clinics and organizations, Workers' Compensation Insurance and its underestimation of non-acute conditions, and surveillance of workers exposed to newly introduced agricultural products. Under surveys, the Department of Labor's NAWS, which is currently in use, employs methodology that has been very successful in tracking hired farm workers. The recent addition of a health supplement to this instrument eventually should make it possible to compare its findings with those from clinic-based surveillance and other local surveys. In addition, it should also be possible to connect the NAWS work with local clinics and thereby obtain medical data from a subsample of survey participants.
Other survey designs, which are essential to national/international studies, are household surveys. The objectives for this approach are to obtain occupational information, to include workers living in "unconventional dwellings," to establish baseline data, and to gather data on injured or ill workers not seeking medical care.
With respect to cross-border surveillance, this entails monitoring hired farm workers between their workplaces here in the U.S. and their permanent homes in Mexico and Central America. One method involves establishing links with the sending villages in Mexico and Central America in order to capture older, retired hired farm workers. A second approach is to develop collaboration among physicians in Mexico and the U.S. A third option is to incorporate the binational methods of the Migrant Clinicians' Network in tracking and monitoring hired farm workers.
Under special populations, pregnant women and women of childbearing age represent the highest priorities. In each case, hazardous work exposures such as chemicals and injuries and their subsequent effect on a woman's pregnancy or her ability to become pregnant are important focal points for project design. With respect to pregnant workers, project design needs to consider a woman's vulnerability to injuries during her pregnancy, especially during the later trimesters. As for women of childbearing age, the key considerations are access to contraceptives, effect of work on miscarriages, and recovery from injuries as compared to men.
The next critical population is children. Of special concern are injuries and cancer. Regarding the former, project design needs to look at how both chronic conditions and traumatic accidents affect a child's development. As for cancer, exposures to pesticides and other chemicals and their link with childhood cancers such as Leukemia are critical components for project design.
The remaining populations all pertain to specific types of agricultural work or workers. These include greenhouse workers, disabled workers, tobacco workers, crab workers, and orchard workers. In the cases of agricultural work, the main considerations for project design are the different types of hazardous exposures that exist in each respective area and determining the prevalence of injuries that are associated with those kinds of exposures. Examples include green tobacco illness, fall from ladders, and pesticide exposures due to contact with foliage. With respect to disabled workers, the primary concerns are prevalence and work status when a worker is no longer able to do agricultural work.
In all seven cases, an important aspect of project design involves measuring the effectiveness of interventions. Accordingly, project design will include means for analyzing preventive efforts such as Personal Protective Equipment, daycare availability, and improved tool designs and determine what impact, if any, these changes have in reducing the prevalence of certain types of adverse health outcomes.
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