Urban and rural healthcare providers' perspectives on HPV vaccination in Minnesota

Human papillomavirus (HPV) vaccination can dramatically reduce the incidence of HPV-associated cancers. However, HPV vaccination coverage in rural areas is lower than in urban areas, and overall HPV vaccination coverage in the United States remains lower than other adolescent vaccines. We conducted 20 qualitative interviews with adolescent healthcare providers and clinic staff in urban and rural Minnesota and assessed their perspectives on HPV vaccination. Guiding interview topics included: strategies to persuade families to vaccinate their children, the impact of the patient-provider relationship and the clinical environment on vaccination uptake, and provider perceptions of parents' vaccine attitudes. In thematic analysis, all participants reported using common vaccination strategies, such as framing the HPV vaccine in terms of cancer prevention. The analysis also revealed three themes described as occurring uniquely or more intensely in rural communities than urban communities: the rural value of choice or independence, the spread of misinformation, and close-knit, multifaceted patient-provider relationships in clinical practice. Interventions aimed at increasing HPV vaccination should consider the distinctive circumstances of rural healthcare providers and patients.

Associations between area-level arsenic exposure and adverse birth outcomes: An Echo-wide cohort analysis

BACKGROUND

Drinking water is a common source of exposure to inorganic arsenic. In the US, the Safe Drinking Water Act (SDWA) was enacted to protect consumers from exposure to contaminants, including arsenic, in public water systems (PWS). The reproductive effects of preconception and prenatal arsenic exposure in regions with low to moderate arsenic concentrations are not well understood.

OBJECTIVES

This study examined associations between preconception and prenatal exposure to arsenic violations in water, measured via residence in a county with an arsenic violation in a regulated PWS during pregnancy, and five birth outcomes: birth weight, gestational age at birth, preterm birth, small for gestational age (SGA), and large for gestational age (LGA).

METHODS

Data for arsenic violations in PWS, defined as concentrations exceeding 10 parts per billion, were obtained from the Safe Drinking Water Information System. Participants of the Environmental influences on Child Health Outcomes Cohort Study were matched to arsenic violations by time and location based on residential history data. Multivariable, mixed effects regression models were used to assess the relationship between preconception and prenatal exposure to arsenic violations in drinking water and birth outcomes.

RESULTS

Compared to unexposed infants, continuous exposure to arsenic from three months prior to conception through birth was associated with 88.8 g higher mean birth weight (95% CI: 8.2, 169.5), after adjusting for individual-level confounders. No statistically significant associations were observed between any preconception or prenatal violations exposure and gestational age at birth, preterm birth, SGA, or LGA.

CONCLUSIONS

Our study did not identify associations between preconception and prenatal arsenic exposure, defined by drinking water exceedances, and adverse birth outcomes. Exposure to arsenic violations in drinking water was associated with higher birth weight. Future studies would benefit from more precise geodata of water system service areas, direct household drinking water measurements, and exposure biomarkers.

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.

Incidence rates of childhood asthma with recurrent exacerbations in the US Environmental influences on Child Health Outcomes (ECHO) program

BACKGROUND

Descriptive epidemiological data on incidence rates (IRs) of asthma with recurrent exacerbations (ARE) are sparse.

OBJECTIVES

This study hypothesized that IRs for ARE would vary by time, geography, age, and race and ethnicity, irrespective of parental asthma history.

METHODS

The investigators leveraged data from 17,246 children born after 1990 enrolled in 59 US with 1 Puerto Rican cohort in the Environmental Influences on Child Health Outcomes (ECHO) consortium to estimate IRs for ARE.

RESULTS

The overall crude IR for ARE was 6.07 per 1000 person-years (95% CI: 5.63-6.51) and was highest for children aged 2-4 years, for Hispanic Black and non-Hispanic Black children, and for those with a parental history of asthma. ARE IRs were higher for 2- to 4-year-olds in each race and ethnicity category and for both sexes. Multivariable analysis confirmed higher adjusted ARE IRs (aIRRs) for children born 2000-2009 compared with those born 1990-1999 and 2010-2017, 2-4 versus 10-19 years old (aIRR = 15.36; 95% CI: 12.09-19.52), and for males versus females (aIRR = 1.34; 95% CI 1.16-1.55). Black children (non-Hispanic and Hispanic) had higher rates than non-Hispanic White children (aIRR = 2.51; 95% CI 2.10-2.99; and aIRR = 2.04; 95% CI: 1.22-3.39, respectively). Children born in the Midwest, Northeast and South had higher rates than those born in the West (P < .01 for each comparison). Children with a parental history of asthma had rates nearly 3 times higher than those without such history (aIRR = 2.90; 95% CI: 2.43-3.46).

CONCLUSIONS

Factors associated with time, geography, age, race and ethnicity, sex, and parental history appear to influence the inception of ARE among children and adolescents.

Health Care Utilization During the COVID-19 Pandemic Among Individuals Born Preterm

Importance

Limited data exist on pediatric health care utilization during the COVID-19 pandemic among children and young adults born preterm.

Objective

To investigate differences in health care use related to COVID-19 concerns during the pandemic among children and young adults born preterm vs those born at term.

Design, Setting, and Participants

In this cohort study, questionnaires regarding COVID-19 and health care utilization were completed by 1691 mother-offspring pairs from 42 pediatric cohorts in the National Institutes of Health Environmental Influences on Child Health Outcomes Program. Children and young adults (ages 1-18 years) in these analyses were born between 2003 and 2021. Data were recorded by the August 31, 2021, data-lock date and were analyzed between October 2021 and October 2022.

Exposures

Premature birth (<37 weeks' gestation).

Main Outcomes and Measures

The main outcome was health care utilization related to COVID-19 concerns (hospitalization, in-person clinic or emergency department visit, phone or telehealth evaluations). Individuals born preterm vs term (≥37 weeks' gestation) and differences among preterm subgroups of individuals (<28 weeks', 28-36 weeks' vs ≥37 weeks' gestation) were assessed. Generalized estimating equations assessed population odds for health care used and related symptoms, controlling for maternal age, education, and psychiatric disorder; offspring history of bronchopulmonary dysplasia (BPD) or asthma; and timing and age at COVID-19 questionnaire completion.

Results

Data from 1691 children and young adults were analyzed; among 270 individuals born preterm, the mean (SD) age at survey completion was 8.8 (4.4) years, 151 (55.9%) were male, and 193 (71.5%) had a history of BPD or asthma diagnosis. Among 1421 comparison individuals with term birth, the mean (SD) age at survey completion was 8.4 (2.4) years, 749 (52.7%) were male, and 233 (16.4%) had a history of BPD or asthma. Preterm subgroups included 159 individuals (58.5%) born at less than 28 weeks' gestation. In adjusted analyses, individuals born preterm had a significantly higher odds of health care utilization related to COVID-19 concerns (adjusted odds ratio [aOR], 1.70; 95% CI, 1.21-2.38) compared with term-born individuals; similar differences were also seen for the subgroup of individuals born at less than 28 weeks' gestation (aOR, 2.15; 95% CI, 1.40-3.29). Maternal history of a psychiatric disorder was a significant covariate associated with health care utilization for all individuals (aOR, 1.44; 95% CI, 1.17-1.78).

Conclusions and Relevance

These findings suggest that during the COVID-19 pandemic, children and young adults born preterm were more likely to have used health care related to COVID-19 concerns compared with their term-born peers, independent of a history of BPD or asthma. Further exploration of factors associated with COVID-19-related health care use may facilitate refinement of care models.

Prenatal Antidepressant Exposures and Autism Spectrum Disorder or Traits: A Retrospective, Multi-Cohort Study

Prenatal antidepressant exposure has been associated with increased risk for neurodevelopmental disorders in childhood, including autism spectrum disorder (ASD). The current study utilized multi-cohort data from the Environmental influences on Child Health Outcomes (ECHO) program (N = 3129) to test for this association, and determine whether the association remained after adjusting for maternal prenatal depression and other potential confounders. Antidepressants and a subset of selective serotonin reuptake inhibitors (SSRIs) were examined in relation to binary (e.g., diagnostic) and continuous measures of ASD and ASD related traits (e.g., social difficulties, behavior problems) in children 1.5 to 12 years of age. Child sex was tested as an effect modifier. While prenatal antidepressant exposure was associated with ASD related traits in univariate analyses, these associations were statistically non-significant in models that adjusted for prenatal maternal depression and other maternal and child characteristics. Sex assigned at birth was not an effect modifier for the prenatal antidepressant and child ASD relationship. Overall, we found no association between prenatal antidepressant exposures and ASD diagnoses or traits. Discontinuation of antidepressants in pregnancy does not appear to be warranted on the basis of increased risk for offspring ASD.

Automation, Climate Change, and the Future of Farm Work: Cross-Disciplinary Lessons for Studying Dynamic Changes in Agricultural Health and Safety

In this review, we first assess the state of agricultural health and safety research as it pertains to the dynamic challenges facing automating agriculture on a warming planet. Then, we turn to social science fields such as rural sociology, science and technology studies, and environmental studies to leverage relevant insights on the introduction of new technologies, environmental risks, and associated workplace hazards. Increased rates of automation in agriculture alongside new risks associated with climate change create the need for anticipatory governance and adaptive research to study novel mechanisms of worker health and safety. The use of the PRISMA framework led to the 137 articles for our review. We identify three themes in the literature on agricultural health and safety: (1) adoption outcomes, (2) discrete cases of health risks, and (3) an emphasis on care and wellbeing in literature on dairy automation Our review led to the identification of research gaps, noting that current research (a) tends to examine these forces separately, instead of together, (b) has not made robust examination of these forces as socially embedded, and (c) has hesitated to examine the broad, transferable themes for how these forces work across industries. In response to these gaps, we suggest that attention to outside disciplines may provide agricultural health and safety research with a toolset to examine needed inquiry into the multiplicity of experiences of rural stakeholders, the industry specific problems arising from automation and climate change, and the socially embedded aspects of agricultural work in the future.

Heritable vaginal bacteria influence immune tolerance and relate to early-life markers of allergic sensitization in infancy

Maternal asthma status, prenatal exposures, and infant gut microbiota perturbation are associated with heightened risk of atopy and asthma risk in childhood, observations hypothetically linked by intergenerational microbial transmission. Using maternal vaginal (n = 184) and paired infant stool (n = 172) samples, we identify four compositionally and functionally distinct Lactobacillus-dominated vaginal microbiota clusters (VCs) that relate to prenatal maternal health and exposures and infant serum immunoglobulin E (IgE) status at 1 year. Variance in bacteria shared between mother and infant pairs relate to VCs, maternal allergy/asthma status, and infant IgE levels. Heritable bacterial gene pathways associated with infant IgE include fatty acid synthesis and histamine and tryptophan degradation. In vitro, vertically transmitted Lactobacillus jensenii strains induce immunosuppressive phenotypes on human antigen-presenting cells. Murine supplementation with L. jensenii reduces lung eosinophils, neutrophilic expansion, and the proportion of interleukin-4 (IL-4)⁺ CD4⁺ T cells. Thus, bacterial and atopy heritability are intimately linked, suggesting a microbial component of intergenerational disease transmission.

Broadening Our Understanding of Farm Children's Risk Exposure by Considering Their Parents' Farming Background

While farm safety researchers have seldom considered the association between farm parents' background and their children's safety, researchers who have compared first- and multi-generation farmers have found differences that may shape safety outcomes. We draw on the farm safety and family farm bodies of literature and a survey of 203 United States farm parents to assess the role of farming background in farm children risk exposure. Exploratory in nature, the bivariate analysis revealed no statistically significant differences between first- and multi-generation farmers in children injury, agricultural safety perceptions, knowledge, and practices but revealed differences in key demographic characteristics and parenting styles. A range of factors likely explain these findings with meso- and macro-level factors likely impacting farm parents' ability to adopt safety practices. In contrast to the emphasis on knowledge and behaviors, we call for the integration of lived realities in farm safety research and to do so in a way that connects realities and choices to larger contexts. We also call on the need to expand the toolkit of interventions to address meso- and macro-level factors. A shift towards addressing social and economic conditions in agriculture could reduce farm children's injuries while supporting the sustainability of farm labor systems.

Exploring Farm Parenting Styles and Child Agricultural Injury

Highlights

Abstract. Four distinct parenting styles have been described: authoritative, authoritarian, permissive, and uninvolved. Parenting styles have been associated with a myriad of child safety and health outcomes. However, the association between parenting style and child agricultural injury has not been explored. This study was conducted among farm parents in Wisconsin and Pennsylvania using a self-administered paper questionnaire. Parents responded to items inquiring about parenting styles, previous child agricultural injuries, personal demographics, and farm characteristics. A total of 238 farm parents responded to the survey. Over a third of respondents (34.3%) reported a child agricultural injury. About 41% of parents were classified as authoritative (demonstrating a high level of involvement and control), 35.7% as uninvolved, 13.3% as permissive, and 10% as authoritarian. In the univariable analyses of parenting style, notable elevations in child injury rates occurred for the authoritarian (RR = 1.96, 95% confidence interval (CI) 1.08 to 3.58, p = 0.0274) and uninvolved (RR = 1.58, 95% CI 1.00 to 2.50, p = 0.0506) categories as compared to the referent category of authoritative. In the multivariable analyses that were adjusted for confounding variables, the magnitude of the corresponding RR estimates were less dramatic, although a 69% elevation was still present for the authoritarian parenting style (RR = 1.69, 95% CI 0.91 to 3.15, p = 0.0975). The results of this study contribute to the growing body of literature suggesting that authoritative parenting is protective against risk-taking behaviors in childhood as well as reducing potential injury among children. Clinicians and safety experts should consider parenting styles when developing child agricultural injury prevention resources or interventions. Keywords: Children, Health, Injury prevention, Parenting styles, Safety.

Finding the Edges of Problems: Social Media as an Exploratory Research Tool

Social media use in public health and other health related research applications has seen a rapid increase in recent years. However, there has been very limited utilization of this growing digital sector in agricultural injury research. Social media offers immense potential in gathering informal data, both text and images, converting them into knowledge, which can open up avenues for research, policy, and practice. There are a number of ways social media data can be utilized in agricultural injury research. This paper touches on the adoption of these data sources in health research and discusses the use of social media as an exploratory research tool that can peer into and identify the edges of potential health and safety problems.

A Farm Kid Paradox

Children are commonly and often fatally injured in agricultural settings that include family farms, constituting fully half of all working youth fatalities in the United States. Yet certain aspects of farm life that expose children to harm are also linked to positive health outcomes, a phenomenon that this essay terms "the farm kid paradox." It reviews applied anthropological research on the differential intertwining of health and hazard, and reflects on the role of the anthropologist as a broker of facts and concepts between diverse stakeholders and farm environments.

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.

Redesigning a Sentinel Surveillance System for Collecting and Disseminating Near Real-Time Agricultural Injury Reports: System Usability Study

Background

Injury data and reports provide valuable information for both public and private organizations to guide programming, policy, and prevention, but in the increasingly complex and dangerous industry of US agriculture, the injury surveillance needed to produce this data is lacking. To address the gap, AgInjuryNews was established in 2015. The system includes fatal and nonfatal injury cases derived from publicly available reports, including occupational and nonoccupational injuries, occurring in the agricultural, forestry, and fishing (AFF) industry.

Objective

The study aimed to develop a stakeholder-engaged redesign of the interactive, up-to-date, and publicly available dataset of US AFF injury and fatality reports.

Methods

Instructor-led heuristic evaluations within a 15-student undergraduate course, data from 8 student participants of laboratory-based usability testing and 2016 and 2017 AgInjuryNews-registered user surveys, coupled with input from the National Steering Committee informed the development priorities for 2018. An interdisciplinary team employed an agile methodology of 2-week sprints developing in ASP.NET and Structured Query Language to deliver an intuitive frontend and a flexible, yet structured, backend, including a case report input form for capturing more than 50 data points on each injury report.

Results

AgInjuryNews produced 17,714 page views from 43 countries in 2018 captured via Google Analytics, whereas 623 injury reports were coded and loaded, totaling more than 31,000 data points. Newly designed features include customizable email alerts, an interactive map, and expanded search and filter options. User groups such as the Bureau of Labor Statistics and the Agricultural Safety and Health Council of America have endorsed the system within their networks. News media have cited or referenced the system in national outlets such as the New York Times, Politico, and the Washington Post.

Conclusions

The new system’s features, functions, and improved data granularity have sparked innovative lines of research and increased collaborative interest domestically and abroad. It is anticipated that this nontraditional sentinel surveillance system and its dataset will continue to serve many purposes for public and private agricultural safety and health stakeholders in the years to come. 

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.

Farm Owners and Workers as Key Informants in User-Centered Occupational Health Prototype Development: A Stakeholder-Engaged Project

BACKGROUND

The cost of workplace injuries and illnesses significantly impacts the overall cost of health care and is a significant annual economic burden in the United States. Many dairy and pork farm owners in the Upper Midwest have expanded operations and taken on the role of manager and employer yet receive little training in injury prevention, farm safety, or workers' compensation programs and processes. Clinicians play a key role in the return to work of injured and ill farmers and farmworkers to their jobs, though little to no formal training is offered by medical schools.

OBJECTIVE

This stakeholder-engaged project aimed to develop a prototype application designed to assist clinicians in returning injured farmworkers to light-duty job assignments with their current employers and to assess farm owners' and managers' attitudes toward and barriers to adopting mobile health tools for themselves or their employees.

METHODS

We conducted 12 semistructured interviews with English-speaking farm owners and farmworkers from the Upper Midwest: 5 English-speaking and Spanish-speaking farmworker focus groups and 8 postproject interviews with farm owners that focused on attitudes and barriers to adoption of the developed software. Interviews and focus groups were audio recorded, and data were analyzed and thematically coded using audio coding.

RESULTS

Interviews and worker focus groups guided an iterative design and development cycle, which informed workflow design, button placement, and output sheets that offer specific light-duty farm work recommendations for the injured worker to discuss with his or her employer.

CONCLUSIONS

The development of a complex prototype intended to impact patient care is a significant undertaking. Reinventing a paper-based process that can eventually integrate with an electronic health record or a private company's human resources system requires substantial stakeholder input from each facet including patients, employers, and clinical care teams. The prototype is available for testing, but further research is needed in the form of clinical trials to assess the effectiveness of the process and the software's impact on patients and employers.

A Review of 2016-2017 Agricultural Youth Injuries Involving Skid Steers and a Call for Intervention and Translational Research

Skid steers or loaders are becoming prolific in U.S. agriculture - as are the injuries and fatalities related to their use. A review of incidents as queried in AgInjuryNews from 2016 to 2017 revealed an overrepresentation of youth being involved in these tragic incidents. This raises concerns over parental attitudes and beliefs about the safety of these machines. Skid steer incidents do not appear to be a result from a lack of safety education materials, however. Indeed, manufacturers, the Centers for Disease Control, and many state extension systems have safety manuals and general instruction, including YouTube videos and online resources. Thus, there appears to be a significant gap between safety knowledge and practice. There is also a lack of published research, including intervention strategies, training evaluation, and translational/implementation studies specific to skid steer machines. This review of youth incidents is therefore also a call for further research for foundational studies regarding attitudes and behaviors involving skid steers in agriculture, intervention models, and efforts to translate prevention knowledge beyond the existing materials.

Augmented Reality Farm MAPPER Development: Lessons Learned from an App Designed to Improve Rural Emergency Response

Fire departments have right-of-entry to most commercial industrial sites and preemptively map them to identify the onsite resources and hazards they need to promptly and safely respond to an emergency event. This is not the case for private farms. Emergency responders are blind to resources and hazards prior to arrival and must spend critical minutes locating them during an emergency response at a farm location. The original 2013 Farm Mapping to Assist, Protect and Prepare Emergency Responders (Farm MAPPER) project was undertaken to develop a method to give emergency responders an up-to-date view of on-farm hazard information to safely and efficiently conduct emergency response activities on private agricultural operations. In 2017, an augmented reality version of Farm MAPPER was developed to combine the technological advantages of geographic information system-based data points with a heads-up display and graphical overlay of superimposed hazard imagery and informative icons. The development and testing of this iOS- and Android-ready prototype uncovered lessons learned applicable to other mobile-based apps targeting farmers, ranchers, and rural populations faced with limited or inconsistent mobile internet connectivity.

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.