Implementing a Community-Based Social Marketing Project to Improve by dyb16396

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									Implementing a Community-Based Social Marketing Project to Improve
Agricultural Worker Health
Joan Flocks,1 Leslie Clarke,1 Stan Albrecht,2 Carol Bryant,3 Paul Monaghan,1 and Holly Baker4
1Department of Health Policy and Epidemiology, College of Medicine, University of Florida, Gainesville, Florida, USA; 2Utah State University,

Logan, Utah, USA; 3Department of Community and Family Health, College of Public Health, University of South Florida, Tampa, Florida, USA;
4Farmworkers Association of Florida, Apopka, Florida, USA



The Together for Agricultural Safety project is a community-based social marketing project             agricultural workers to implement. Workers
working to reduce the adverse health effects of pesticide exposure among fernery and nursery           may not have daily access to washing
workers in Florida. In 3 years, the collaboration between university and community researchers         machines or showers. Many workers are paid
has embodied many of the principles of community-based research while completing multiple              a piece rate and are too pressed for time dur-
stages of formative data collection required for a social marketing project. This hybrid approach to   ing the workday to adhere to safety precau-
developing a health intervention for a minority community has been successful in its early stages      tions. For example, fernery workers are paid a
because the community partners are organized, empowered, and motivated to execute research             certain amount for each bunch of ferns they
activities with the assistance of academic partners. However, this work has also been labor            cut. Because they must focus on picking as
intensive and costly. This article describes the lessons learned by project partners and considers     many bunches as possible, they may not take
the limitations of this approach for agricultural health research. Key words: agricultural worker
                                                                                                       the time to wash their hands every time they
health, community-based research, environmental health, pesticides, social marketing. — Environ
                                                                                                       break for food, water, or to use the bathroom.
Health Perspect 109(suppl 3):461–468 (2001).
http://ehpnet1.niehs.nih.gov/docs/2001/suppl-3/461-468flocks/abstract.html
                                                                                                           One way agricultural workers have
                                                                                                       empowered themselves to try to reduce the
                                                                                                       adverse health effects of pesticide exposure
                                                                                                       has been through the educational efforts of
Agricultural workers and their families             the U.S. Environmental Protection Agency           community-based organizations. In Florida
represent a low-income community of color           Worker Protection Standard (WPS) (15)              the Farmworker Association of Florida
at increased risk for exposures to environmen-      require employers to provide basic safety          (FWAF) has been instrumental in such
tal contaminants such as pesticides (1–4).          measures against pesticide exposure such as        efforts. The FWAF is a grassroots member-
Workers in all agricultural industries experi-      hand-washing facilities, pesticide safety train-   ship organization that has advocated for
ence dermal, oral, and respiratory contact          ing, and decontamination sites. The WPS            Florida agricultural workers for more than 15
with a variety of pesticides known to be            also requires employers to post specific infor-     years. The group offers worker safety training
harmful to humans (5,6). This exposure can          mation about pesticides being used and to          that was developed by the National
result in a variety of acute symptoms such as       provide instructions to workers about how to       Farmworker Health and Safety Institute (18)
headaches, dizziness, nausea, and shortness of      prevent pesticides from entering the body          and is based on interactive, popular education
breath, and health problems such as asthma,         through proper skin and clothes washing.           theory. However, the FWAF has not been
dermatitis, and acute pesticide poisoning           Pesticide safety training recommendations          able to reach as many workers as it would like
(5,7–10). Animal and some human studies             include washing before eating, drinking,           nor has it been able to substantially alter the
have shown pesticides can also have chronic         using chewing gum or tobacco, or using the         ways in which most employers typically train
effects on the neurologic, respiratory,             toilet; washing/showering with soap and            their workers at the worksite.
immune, and reproductive systems and can            water, shampooing hair, and putting on clean           Health science researchers at the
be carcinogenic and mutagenic (2,11–14).            clothes after work; and washing work clothes       University of Florida (UF) in Gainesville,
    Fernery workers in central Florida exem-        separately from other clothes before wearing       Florida, joined efforts with the FWAF and a
plify a population that experiences frequent,       them again (15).                                   social marketing firm, Best Start, Inc., to
intense pesticide exposure. These workers               Yet, studies show workers are often not        obtain funding to expand the efforts at the
often have full-body contact with ferns they        informed about the chemicals used in their         FWAF to reduce pesticide exposure among
are cutting and thus with any pesticide that        workplaces nor provided access to the facilities
has been sprayed onto the plants. Workers are       needed to reduce health risks, such as clean
surrounded on all sides by ferns that can grow      water and soap for washing (5). In their study
                                                                                                       This article is based on a presentation at the Workshop
thigh high. Throughout the day workers              of North Carolina agricultural workers,            on Farmworkers and Pesticides: Community-Based
bend over and thrust their arms into masses         Ciesielski et al. (5) found 58% of workers sur-    Research held at the American Public Health
of ferns in order to cut the fronds at the          veyed reported water was not available to wash     Association Meeting on 7 November 1999 in Chicago,
                                                                                                       Illinois, USA.
plant’s base.                                       hands during work. In Florida, WPS regula-              Address correspondence to J. Flocks, Dept. of
    Fern cutters often labor in fields enclosed      tions are poorly enforced, violations are          Health Policy and Epidemiology, 1329 SW 16th St.,
by black mesh netting. Chemicals cannot dis-        underreported by workers who fear retribu-         Room 5232, Gainesville, FL 32608 USA. Telephone:
                                                                                                       (352) 265-8041. Fax: (352) 265-8047. E-mail:
sipate as easily in these enclosed areas as in      tion, and few violators who are identified are      jflocks@hpe.ufl.edu
open fields, and this can increase workers’         penalized (17). An investigation by agricul-            This study was supported by research grants R21-
exposure levels. Because of this increased dan-     tural worker advocates in Florida reported that    ES08766 and R13-ES10197 from the National Institute
ger, some protective regulations are stricter       there were only 46 complaints of worker            of Environmental Health Sciences. Full protection of all
                                                                                                       human subjects was adhered to in this research
for industries such as ferneries than for other     injury due to agricultural use of pesticides in    through giving oral explanation and obtaining written
agricultural industries (15).                       Florida from January 1992 to mid-May 1997,         informed consent, provided in Spanish and Haitian
    Federal regulations such as the                 and that the state issued only two fines (17).      Creole to non-native speakers, before research activi-
                                                                                                       ties occurred.
Occupational Safety and Health Adminis-                 Furthermore, recommended safety                     Received 24 November 2000; accepted 13
tration Field Sanitation Standard (16) and          measures are often difficult for many              February 2001.



Environmental Health Perspectives   • VOLUME 109 | SUPPLEMENT 3 | June 2001                                                                             461
Flocks et al.


central Florida’s farmworkers. In 1997 this        workers in the nursery industries and about          Social Marketing Framework
partnership of community-based and acade-          13,000 workers in the fernery industries in five      Social marketing was selected as the concep-
mic organizations obtained 4 years of funding      central Florida counties. These workers are pri-     tual framework to guide consumer research,
from the National Institute of Environmental       marily Mexican, but there are also small             strategy development, analytic techniques,
Health Sciences. The partners formed the           groups of Haitian and African-American work-         and program monitoring to identify ineffec-
Together for Agricultural Safety/Unidos para       ers. In the fernery industry, workers are paid       tive activities that require modification and
la Seguridad Agricola/Tet Ansamn pou               by the piece. In the nursery industry, workers       effective activities worth sustaining. Social
Sekirite Agrikilti (TAS) project to assist agri-   are paid primarily by the hour, although some        marketing is
cultural worker communities in creating            are paid by the piece and by the hour.
                                                                                                            the application of commercial marketing
effective solutions to the problem of pesticide        To accomplish its intervention goal, the             technologies to the analysis, planning, exe-
exposure. The specific goals of TAS are to         TAS team relied on community-based                       cution, and evaluation of programs
design, implement, and evaluate a health           research principles (19) and social marketing            designed to influence voluntary behavior
intervention to reduce the adverse health          methods (20) in all its data collection activi-          of target audiences in order to improve
effects of pesticide exposure among central        ties. Community-based research empowers                  their personal welfare and that of their
Florida fernery and nursery workers. The           academic and community partners through                  society. (23)
TAS research process adheres to community-         cooperative research and action (21). Social
based research principles and a social             marketing provides the conceptual framework          A community-based approach to social
marketing research framework.                      that guides the research and strategy develop-       marketing requires that community partners
    The roles of the UF researchers in the pro-    ment process. The TAS academic and com-              become active participants in setting goals
ject include providing project management          munity partners conducted five qualitative           and directing each phase of the marketing
and administration; experience and training in     and quantitative research activities using these     process. Academic researchers work with
data collection, analysis, intervention develop-   principles and methods. The following sec-           community partners to use a systematic, data-
ment, and program evaluation; and dissemi-         tions elaborate on community-based research          driven marketing model to design effective
nation of project results through professional     principles and the social marketing frame-           behavior change strategies. Through this col-
forums. The Best Start, Inc. consultant devel-     work and how these principles were applied           laborative participation and the resulting
ops and guides the project team through a sys-     in the TAS data collection activities.               increased competence, community partners
tematic social marketing process from                                                                   and groups gain more power over social and
conducting formative research activities to        Community-Based Principles                           tangible resources (24,25).
designing and testing intervention material.       A community-based approach was adopted by                The bedrock of the social marketing
    The FWAF provides access to the nursery        TAS because of the increasing recognition            approach is extensive formative research,
and fernery communities, assists with project      that community participation contributes to          which involves data collection activities con-
management, and grants staff members and           the success of health promotion programs             ducted before a program begins in order to
staff time to conduct research activities.         (22). Community-based research involves an           understand how consumers perceive a prod-
Furthermore, the FWAF staff’s insight and          explicit concern for the organizational and          uct, its price, and other factors that influence
knowledge of the reality of workers’ lives is      community aspects of public health (21).             consumer behavior (such as the marketing
one of the most valuable components of the         Israel et al. (19) describe it as “ … an ecologi-    concepts of price and promotion). Research is
project, especially in the development of data     cal approach that recognizes that individuals        used in social marketing to segment the target
collection instruments.                            are embedded within social, political and eco-       population into homogeneous subgroups
    This article describes the nature and          nomic systems that shape behaviors and access        based on characteristics that influence their
quality of partner participation and inter-        to resources necessary to maintain health.” In       responsiveness to marketing interventions,
actions as the TAS team collected data to          contrast to health interventions that focus          such as the product benefits they find most
guide the development of the intervention.         exclusively on individual behavior, TAS part-        attractive. Research results guide the selection
The purpose of this discussion is to explain       ners wanted to also focus on the social and          of segments to be targeted and the develop-
how community-based research in environ-           occupational factors that affect agricultural        ment of a comprehensive marketing plan to
mental health can be carried out jointly by        worker behavior, such as working conditions          reach each target segment. The marketing
community and academic partners. We                and the pressure of surplus worker availability      plan includes activities designed to modify
extend beyond the theoretical discussions of       on workers’ willingness to challenge worksite        structural factors (e.g., policies or availability
how community partners and academics can           practices. The team believes a community-            of equipment or washing facilities) as well as
work together to describe the actual activities    based approach is necessary to develop strate-       motivate target audiences to change their
of the collaboration, what the roles of the        gies that are culturally viable and sustainable.     behavior (26).
partners were, and the pros and cons of col-       The elements of a community-based
laborative research activities. This article       approach incorporated into the TAS project           TAS Project Research Activities
focuses on the process of conducting this          include: a) participation of community part-         In the first 3 years of the project, the TAS
community-based research rather than on            ners in all phases of the project, including         team conducted five different formative
research findings or the creation of the inter-     research; b) promotion of co-learning and            research activities. In order to adhere to
vention to reduce pesticide exposure.              empowerment of all partners through recip-           community-based research principles, the
                                                   rocation of skills and knowledge; c) accep-          team decided at the beginning of the project
Methods                                            tance of the research activities as cyclical,        to carry out all activities only through collab-
Nursery and fernery workers were selected for      (e.g., sometimes strategies need to be recon-        oration. Although it was not practical for
this project because they are exposed to high      sidered and new data must be collected); and,        every team partner to participate in every
levels of pesticides and because they generally    d ) broad dissemination of project knowledge,        activity, the team could jointly decide which
do not migrate, making it possible to work         not only among TAS partners but to workers,          combinations of partners were best suited to
with them throughout the year. The FWAF            employers, healthcare providers, and other           complete certain tasks. These decisions were
estimates there are between 10,000 and 12,000      community members (19).                              made at regular team meetings.


462                                                                           VOLUME   109 | SUPPLEMENT 3 | June 2001 • Environmental Health Perspectives
                                                                                                       A community-based social marketing project


    This approach is more time intensive and         the community partners; analyzed the data;        Results were presented to the entire TAS
complex than unilateral decision making, but         wrote the summary; and reviewed, edited, and      team during a general meeting, which helped
it promotes empowerment and a feeling of             discussed the summary. Five community part-       assure a more balanced interpretation of
equitable ownership and generates a broader          ners participated in these groups as modera-      what the providers said and educated all par-
range of insights than a single decision maker       tors, and two academic partners participated      ties on how healthcare providers viewed the
could gain. Working collaboratively on               as co-moderators.                                 problem of pesticide exposure.
research activities provides a reiteration of the        The team conducted 16 focus groups
project’s goals and allows for a mutual reflec-       with the following categories of participants:    Employer/Supervisor Interviews
tion on the journey to reach those goals.            male or female workers who either had no          The TAS team determined interviews with
Finally, the TAS project team believes the           children or had children younger than 10          employers and supervisors were necessary to
collaborative approach will ensure sustainabil-      years of age; male or female workers with         understand the structural problems associated
ity of project efforts and encourage future          children older than 10 years; and older work-     with occupational pesticide exposure and
collaboration between the team partners.             ers. The groups were generally assembled          safety practices. Because the FWAF is a
    The following sections describe the TAS          according to gender, ethnicity, and occupa-       worker advocacy group, the project team
collaborative data collection activities and         tion. The decision to form groups according       agreed employers would be more likely to
include explanations of how tasks were divided       to ethnicity (Mexican or Haitian) and occu-       respond to interviews conducted by the acad-
between community and academic partners.             pation (nursery or fernery) was based on the      emic partners. Although three community
                                                     critical differences in work experiences and      partners made contact with and helped to
Participant Observation                              safety practices between these communities.       interview supervisors they knew at ferneries
Early in the project, the community partners         All focus groups were conducted either in         and nurseries, only academic partners con-
asked academic partners to spend a few days          Spanish or in Haitian Creole.                     tacted and interviewed employers.
working in the fern fields and nurseries to get                                                              The employer interviews brought up
a more realistic view of workers’ situations.        Healthcare Provider Interviews                    important issues about confidentiality.
Two community partners facilitated these             Community partners informed the TAS               Employers may have been reluctant to be
workdays by making arrangements with                 team that workers are concerned about gain-       interviewed if they thought the information
employers and supervisors they knew, who             ing access to healthcare and about the            they provided would be reported to worker
agreed to allow the academic partners to work        response of healthcare providers to workers’      advocacy organizations. Therefore, the inter-
at their businesses. Four academic partners          general health problems and possible pesti-       viewer assured all employers that even though
worked for a day in a fernery and three              cide-related symptoms. The team decided to        the interviewer was working with the FWAF,
worked for a day in two nurseries. In addition       gain a better understanding of healthcare         all employers’ identities would be confiden-
to working, the academic partners talked with        provider knowledge of pesticide-related ill-      tial, and interview results would be presented
and observed other workers and conducted             nesses and the barriers workers face in getting   only in a summary for research purposes. A
quick ethnographic assessments of the work-          adequate healthcare in the target communi-        total of 25 employer and supervisor inter-
sites. The entire TAS team participated in           ties. The team also realized that healthcare      views were completed.
debriefing the academic researchers about            providers could be a potential target audi-
their work experiences at a general team             ence for intervention and that it was there-      Household Surveys
meeting. This activity was critical to the pro-      fore important to gather information from         After gathering qualitative data, the next step
ject, as it provided the academic partners with      this sector of the community.                     in the TAS community-based social market-
first-hand experience in the realities of fernery         Community partners identified public and       ing approach was to identify factors associated
and nursery work and the constraints on              private providers who served nursery and fern-    with target behaviors. Based on extensive
workers’ behaviors.                                  ery workers. One community partner con-           analysis of the focus group data, the TAS
                                                     tacted providers, conducted personal and          team selected two behaviors with the poten-
Focus Groups                                         telephone interviews, transcribed and analyzed    tial to impact pesticide exposure: hand wash-
The project team used focus groups to                interview results, and helped prepare presenta-   ing and adherence with entry interval
develop an understanding of workers’ atti-           tions of these results. Three academic partners   regulations. Focus group results were also
tudes and behaviors regarding pesticide use.         also contacted providers and conducted per-       used to identify predictors of these behaviors
These groups also generated qualitative data         sonal interviews, analyzed interview results,     (perceived benefits, costs, social norms, etc.)
that were instrumental in developing the sur-        prepared presentations, and sent the result       and the vocabulary workers use to discuss
vey questionnaire and in understanding survey        summary back to the interview providers.          pesticide exposure. A large question pool was
results. Community partners attended train-              The team conducted 14 face-to-face and        developed and distributed to the entire team
ing on focus groups; collaborated on the ques-       telephone interviews with healthcare              for review and comment. During several
tioning guide; scheduled the groups;                 providers in four counties. These providers       meetings the TAS team discussed the relative
contacted participants; moderated; partici-          included doctors, nurses, and outreach work-      importance of each item, selected items for
pated in debriefings; translated and tran-           ers. About one third were private practition-     the survey, and revised the wording of many
scribed tape recordings of the groups;               ers, and the rest worked at public or             items. The partners who developed the survey
reviewed transcriptions with an academic             community health clinics. The interview           wrote approximately 20 drafts before the team
partner; reviewed, edited, and discussed the         questions focused on providers’ practices         felt the instrument was ready for translating
summary; and presented the summary to                related to workers, their general knowledge       and pretesting with workers.
community members. Academic partners also            of workers’ health concerns, barriers in pro-
attended training on focus groups; collabo-          viding services for these workers, and knowl-     Pretesting the Survey Instrument
rated on the questioning guide; scheduled            edge of pesticide-related illnesses and           The draft survey instrument was translated
groups in some cases; brought and monitored          reporting requirements. The results of the        into Spanish and Haitian Creole. An acade-
recording equipment; took notes; participated        interviews were compiled and summarized           mic partner and a community partner
in debriefings; reviewed transcriptions with         for use in guiding later parts of the project.    pretested the survey with 16 Haitian nursery


Environmental Health Perspectives    • VOLUME 109 | SUPPLEMENT 3 | June 2001                                                                    463
Flocks et al.


workers, and a community partner pretested it        in that activity were asked to briefly answer              under which fern and nursery workers
with 12 Hispanic nursery and fernery workers.        the following questions:                                   work. Care was taken on the part of FWAF
                                                                                                                staff to select places where the conditions
                                                     • What did you or your group (FWAF, UF,                    were not the worst nor the best so the expe-
Mapping and Sampling                                     Best Start, Inc.) gain from this activity?             rience would not be too weighted. At the
The project partners agreed a random sample          • Do you think this activity helped advance                first project meeting after the work days,
of workers across categories of ethnic groups,           the TAS project, and if so, how?                       the academic partners came in and started
occupational groups, and geographic commu-           • How did this activity affect the relation-               by saying the ideas that they had originally
nities would provide the most valid set of               ship between the community and acade-                  had and why they now knew why they
information on worker behaviors and atti-                mic partners in this project?                          wouldn’t work.
tudes about pesticide exposure. However,                 Respondents either wrote down their own
because no enumeration of workers was avail-         comments or dictated their comments to                    Academic partner’s comment on partici-
able for the target communities, the team had        another partner who transcribed them. This             pant observation.
to enumerate all potential worker residences.        exercise was designed to encourage TAS pro-
                                                                                                                Participant observation provided the acad-
For Hispanic workers the team selected 13            ject team partners to reflect on the research              emic partners with firsthand understand-
communities, and several teams blocklisted           activities, to participate in an internal assess-          ing of the tasks farmworkers conduct each
individual worker households by drawing              ment of the strengths and weaknesses of the                day and the ways in which they are
maps of every home believed or known to be a         project, and to collaborate on producing a                 exposed to chemicals during the workday.
household of fernery or nursery workers. This        balanced summary of the research activities.               It also gave the team an understanding of
process resulted in a listing of the residences of   It created a collective documentation of the               the many factors that influence farmwork-
more than 1,000 workers. From these lists, an        project’s history and served as a tool to help             ers’ behaviors, especially those related to
academic partner randomly selected on a              the project move forward to the next step—                 pesticide exposure, and allowed researchers
computer samples of respondent households.           designing and implementing the health inter-               to assess the ease with which a variety of
                                                                                                                protective measures could be adopted. For
    Because the Haitian nursery worker com-          vention (27). When these comments are                      example, only a few hours of work in the
munity is more dispersed than the Mexican            presented in academic forums, it allows com-               ferneries convinced the team that protec-
worker population, Haitian workers were              munity partners’ perspectives on research to               tive gloves would be impractical to recom-
enumerated by a community partner and an             be considered in arenas where they are some-               mend to fernery workers because of the
academic partner through a snowball sam-             times overlooked.                                          discomfort and impact on productivity.
pling process. Haitian interviewers and survey
respondents were asked for names of other            Results of the TAS Project
                                                     Process Evaluation                                     Focus Group Research
Haitians who work in nurseries. The Haitian
nursery worker community is small and more           This section presents the results of the self-         The comments on the focus groups indicate
tight-knit, and the project team believed it         evaluation exercise in the form of brief sum-          the importance of this activity in defining the
would be possible to find and survey the             maries, followed by the direct comments by             problem to be addressed, even for the commu-
complete population in this manner.                  community and academic partners related to             nity group. The significance of language and
                                                     each TAS research activity. These quotes are           how workers characterize pesticides exposure
Surveying                                            reprinted here with the full knowledge and             expanded all partners’ perspectives. Although
Eight Hispanic and Haitian interviewers were         permission from their authors. Some quota-             the activity did not have a material impact on
originally recruited from the FWAF and from          tions have been edited for brevity, either by          the partners’ relationships, according to the
target communities. One academic partner             the author or with permission of the author.           community partner, it did help to establish
also participated as an interviewer. An acade-                                                              that the partners would work cooperatively.
mic partner conducted a training session for         Participant Observation                                    Community partner’s comment on focus
the interviewers about the project and the sur-      The workdays enhanced mutual trust                     groups.
veying goals, how to administer informed             between the partners. It was the first data col-
                                                                                                                I think this activity was good for the
consent and research surveys, how to track           lection activity. Although this type of partici-           FWAF because for the first time we gath-
attempted and completed interviews, and how          pant observation is a common ethnographic                  ered a variety of people of different ages
to document subject responses. Interviewers          research activity, the TAS workdays occurred               and gender. It gave me ideas to use for
practiced and sometimes conducted interviews         largely because of the strong suggestions and              other meetings. The translation process
in pairs.                                            arrangements made by the community part-                   was interesting. I have never had the expe-
    These data collection activities appropri-       ners. The academic partners’ participation in              rience of having every single word trans-
ately defined the problem from many per-             this activity helped them earn the trust and               lated. There were words that have specific
spectives by gathering information from a            respect of the community partners. It also                 meanings in this community that needed
range of stakeholders about knowledge,               provided the academic partners with a critical             to be explained through the translation
                                                                                                                and we did that. It helped having bilingual
beliefs, and practices regarding pesticide           perspective of the realities of farm work and              people working on this activity. I think
exposure. Because of the collaboration the           pesticide safety measures. These TAS partners              this activity helped the project. For exam-
outcomes of participation were effective and         continue to draw on their workday experi-                  ple, at first I did not understand where the
equally shared, and partners grew in their           ences in designing the program intervention.               questions in the worker survey came from.
knowledge of one another and in their                As a data collection exercise, the workdays                Now I realize that the questions came
knowledge of the challenges to agricultural          helped in developing the focus group ques-                 directly from the information in the focus
worker protection.                                   tions as well as subsequent survey questions.              groups. In other studies, we worked just
    After completing the formative research              Community partner’s comment on                         from instructions and the information was
phase of the project, the entire TAS team par-       participant observation.                                   not shared with the community. In this
                                                                                                                project, we are working together and creat-
ticipated in a process evaluation activity. For
                                                         This workday plan proved to be valuable in             ing new solutions together and the FWAF
each activity at least one academic partner             our overall collaborations together. The aca-           can answer the community’s questions
and one community partner who participated              demic partners saw firsthand the conditions              about the study.


464                                                                               VOLUME   109 | SUPPLEMENT 3 | June 2001 • Environmental Health Perspectives
                                                                                                            A community-based social marketing project


   Academic partner’s comment on focus                     related health problems. Third, they             Survey of Workers
groups.                                                    allowed us limited opportunities to sensi-       Comments on the survey process, from ques-
                                                           tize the health provider community to
                                                           these issues. We learned several things.
                                                                                                            tionnaire development to data analysis, reflect
   The focus groups were helpful to the acade-
   mic partners because they provided a body               Among the most important was the limited         some shared frustrations. First, most of the
   of rich, ethnographic data that would have              understanding that most healthcare               partners agreed the survey development
   otherwise taken a long time to gather. This             providers have of pesticide-related illnesses.   process was long and sometimes tedious.
   data has been valuable in interpreting the              Diagnosis is a difficult problem and the         Community-based research is known to be
   worker survey results because anyone look-              hurdles they have to go through to have          more time-consuming than that conducted
   ing at the survey answers knows more about              something linked to pesticide exposure are       solely by academic researchers (19). The
   their true meaning. For example, the survey             daunting. Another possible outcome was           social marketing emphasis on extensive for-
   data may show that a high percentage of                 the potential future extension of the project    mative research also added to the time
   workers say that their employers always post            to include health provider training.
                                                                                                            demands required to complete this activity.
   warning signs indicating that area has been
   recently sprayed with pesticides. But from
                                                                                                            However, partners also agreed the results pro-
                                                       Employer and Supervisor Interviews                   duced by the survey process were worth the
   the focus groups we know that at least in
   one industry, the signs are always up or            Initially, the community partners were               time invested. These results included not only
   always up and folded shut—whether or not            reluctant to contact employers about the pro-        materials such as a collection of community
   there has been an application.                      ject. However, after the interview summary was       maps and a large amount of survey data, but
                                                       presented to the team partners, they realized an     less obvious benefits, such as the sense of
Healthcare Provider Interviews                         effective intervention must include working          equitable ownership of data and knowledge
                                                       with owners and supervisors rather than work-        of research methods. Finally, the academic
This activity was a further step in the joint          ing as adversaries. Employers have ultimate          partners’ comments about the survey process
collection of data that presented new infor-           control over their workplaces, and supervisors       reflect why community-based research can be
mation to both parties. Unanticipated find-            have daily control over workers. Interviews          so valuable when working with populations
ings led TAS partners to an increased concern          with these two groups showed their perceptions       such as agricultural worker communities. In
about the role of healthcare services in edu-          of occupational pesticide exposure often differ      this activity the community partners provided
cating and treating agricultural workers who           from those of the workers. For a health inter-       the culturally appropriate language needed for
experience pesticide exposure. This activity           vention to succeed in the workplace, where           the questionnaire, access to an often hidden
also resulted in the project adding a new              owners and supervisors have control, it must be      population, and the time and work needed to
dimension of intervention planning that                based on some common ground shared by all            complete the survey.
involves healthcare providers.                         affected groups. The TAS team determined a               Community partner’s comment on devel-
    Community partner’s comment on                     workplace intervention would be less successful      oping the survey instrument.
healthcare provider interviews.                        and sustainable if the burden of behavioral
                                                                                                               While the number of revisions of the sur-
                                                       change were placed solely on one group.                 vey became very tedious at times, everyone
   Interviewing healthcare providers con-
   firmed the thoughts that FWAF had about                  Community partner’s comment on                      really got into it and gave very good
   the care being received by farmworkers.             employer/supervisor interviews.                         insights, which enabled the finished prod-
   That is, most times there is no connection              This activity helped advance the project            uct to be ‘owned’ by everyone, who were
   made between occupation and symptoms,                   because we have the point of view and               therefore committed to using it in the best
   therefore, there is usually no correlation              opinion of the employers. We can identify           way possible. I believe the whole process
   between illness and pesticides recorded in              how we can reduce exposure of workers to            speaks strongly to ‘ownership’ by all and a
   the patients’ file. Because the doctor’s                pesticides by knowing the feelings of the           sense of a strong, respectful partnership.
   opinion holds a lot of weight with farm-                employers. This activity affected the rela-         By being a part of this process, FWAF
   workers, a doctor’s decision about whether              tionship between FWAF and academic                  learned about all the factors that must be
   to make a connection of symptoms to pes-                partners in a positive way. It shows that we        considered to develop a survey that can
   ticides or occupation could affect the farm-            can do things to complement each other.             produce thorough and valuable results.
   workers’ interpretation of the dangers of                                                                   This activity helped advance the project
   workplace chemicals. Also, since the pro-                                                                   because the careful scrutiny of the focus
   ject’s health intervention has not yet been            Academic partner’s comment on employer               group data, followed by thorough revisions
   designed and healthcare providers are a             and supervisor interviews.                              of the survey instrument, allowed us to
   possible target audience, this was vital                                                                    develop the final questionnaire derived
   information to obtain for decision making               The academic partners learned that for              from worker knowledge shared with us.
   within the project team regarding the                   smaller nursery firms, employees are long-
   intervention.                                           term and year-round and owners establish
                                                           personal relationships and try to keep               Academic partner’s comment on develop-
                                                           employees. Nevertheless, the pay is low,         ing the survey instrument.
    Academic partner’s comment on health-                  there is no overtime, and few employers
                                                                                                               The community team provided valuable
care provider interviews.                                  offer benefits like health insurance.
                                                                                                               input into the development of the survey
                                                           Employers are worried about the labor
   The interviews with healthcare providers                                                                    instrument, suggesting the appropriate
                                                           market, but none seemed concerned about
   were useful to the larger project for several                                                               vocabulary to use for each item, helping to
                                                           pesticide danger or how it may affect
   reasons. First, they allowed our research                                                                   identify potential response values for many
                                                           employee loyalty. This may play a role in
   team to obtain some understanding of the                                                                    items and generally ensuring that the ques-
                                                           future social marketing: safety may be used
   perceived seriousness of health problems                                                                    tions were culturally appropriate and easy
                                                           as a way for employees to evaluate a good
   associated with worker exposures to pesti-                                                                  to understand. Discussions about individ-
                                                           firm. Owners also felt that once employees
   cides from the perspective of health                                                                        ual items also generated valuable insights
                                                           get information on pesticides they begin
   providers. Second, they allowed us to gain                                                                  into feasibility of potential interventions.
                                                           complaining about the effects. But the
   some sense of health provider interest in                                                                   Although the time and patience required
                                                           burden for protection currently weighs
   and familiarity with pesticide exposure-                                                                    to develop a survey together greatly
                                                           more on the employees’ shoulders.


Environmental Health Perspectives      • VOLUME 109 | SUPPLEMENT 3 | June 2001                                                                           465
Flocks et al.

    exceeded that usually required for this task,                             them from dedicating good time. Even                      The model also summarizes the five main
    the end result was well worth the effort. I                               when we hired Hispanic staff part-time,                   data collection activities completed during
    also believe the exercise reinforced our                                  some found it too difficult and dropped
    commitment to conduct the formative                                       out, although others were able to really
                                                                                                                                        the formative research stage of the project.
    research in a collaborative fashion and con-                              work well in the process.                                      In the conceptual model of Arcury et al.,
    tributed to our skills in working as one                                                                                            different types of community representation
    team rather than separate academic and                                    Academic partner’s comments on surveying.                 can be involved in different modes of interac-
    community subteams.                                                                                                                 tion (28). A community can be represented
                                                                              The completed surveys have generated a
                                                                              large amount of data that the project team                by an existing community group, community
  Community partner’s comment on                                              will use to design its health intervention.               groups created by researchers, community
mapping and sampling.                                                         Language barriers prevented most of the                   leaders, and other community individuals. In
                                                                              academic partners from actually conduct-                  TAS, an existing community group, the
    The FWAF gained a lot from this activity.
    I had training on mapping in the past but                                 ing any of the interviews – which could                   FWAF, serves as the lead community organi-
    it was just to map the fields. I was sur-                                 have contributed to their understanding of                zation, but other important community
    prised at the number of worker houses that                                workers’ realities. There was also a sense                members such as employers and health pro-
    we found during the mapping. It will help                                 that if academic partners had accompanied                 fessionals are also involved. The TAS com-
    me in my organizing work. It gave us maps                                 interviewers, it might have made the inter-               munity partners are full participants in each
    and information that will help the FWAF                                   viewers or respondents uncomfortable.
                                                                              Thus, most of the academic partners were
                                                                                                                                        phase of the research. Using the domains of
    staff here conduct their work for the cen-                                                                                          participation outlined by Arcury et al. (28),
    sus. It helped the organizers here establish                              far enough removed from this particular
                                                                              interviewing process that they did not gain               they are involved in consultation (discussion
    contact with the worker families.                                                                                                   and questioning); strategic planning (collabo-
                                                                              of sense of the challenges it presented for
                                                                              the interviewers, nor could they evaluate                 ratively designing the research); and imple-
   Academic partner’s comments on mapping                                     the success of the survey instrument, the                 mentation (assisting with data collection,
and sampling.                                                                 interviewer training, or the comprehension                analysis and interpretation).
                                                                              of the respondents. Although the general                       Because of the extent of collaboration in the
    Mapping specified size of target population                                feeling was that the community partners
    and the sampling improved data reliability                                                                                          TAS project, outcomes of participation are
                                                                              did an outstanding job of interviewing, it
    This activity advanced the project greatly                                                                                          effectively and equally shared, partners grow in
                                                                              may be beneficial for all parties if academic
    by producing valid, representative survey                                 partners played a more direct role in the                 their knowledge of one another and in their
    results that the project can use to develop                               interviewing process.                                     knowledge of the challenges to agricultural
    the intervention. It also improved the rela-                                                                                        worker protection. Through the TAS model,
    tionships between partners through coop-                                                                                            academic researchers work with community
    erative work, i.e., academic and                                     Discussion                                                     members to use a systematic, data-driven mar-
    community partners worked side-by-side.                              These data collection activities appropriately                 keting model to design effective behavior
                                                                         defined the problem of how to reduce pesti-                     change strategies. Three years into the project,
    Community partner’s comment on                                       cide exposure from many perspectives, by                       the partners found this collaborative approach
surveying.                                                               gathering information from a range of stake-                   to research to be effective, and the community
                                                                         holders about knowledge, beliefs, and prac-                    group has become empowered to collect and
    I believe that we learned a little more
    about what was integral to this project. We                          tices regarding pesticide exposure. The TAS                    use data to address local problems, as was noted
    learned how important it is for everyone as                          approach is similar to the multimode, mul-                     in the quotes above. Although perceived to be
    a group and a community to follow a                                  tidomain model described by Arcury et al.                      tedious at times, the community partners have
    process and a series of steps within a pro-                          (28). This model regards communities as                        come to appreciate the value of careful data col-
    ject in order to get a result that will always                       multidimensional and posits that modes of                      lection and have learned to rely on these data to
    be well focused on getting a solution.                               interaction and domains of participation with                  guide their activities. The academic partners
    The recruitment of additional leaders to                             the communities of interest should also be                     have learned about the many facets of agricul-
    help with the surveys didn’t work well in                            multidimensional to be most effective (28).                    tural work, regulation and enforcement of
    all cases. In the Haitian community, they                            We use the model of Arcury et al. to depict                    worker safety laws, workers’ beliefs and prac-
    already had full-time jobs and I believe the                         the involvement of the community and level                     tices related to pesticide exposure, and individ-
    little time they had for themselves deterred                         of intensity of partnership activities (Table 1).              ual and community perceptions of pesticides.

Table 1. TAS Activities by modes, domains, and their outcomes.a
                                                                                                 Domains of participation (from least to most intensive)
Modes of interaction                                   Consultation                 Strategic planning              Implementation                                Outcomes
Partnership with community group                Monthly meetings                 Shared decision making       Cooperative implementation         Partners share goals, knowledge, skills
Formative data collection activities
   Participation/observation                    Partners discuss needs           Partners cooperatively       Partners share staff hiring,       Academic partners experience farmwork and
   Focus groups                                  for certain types of             plan data collection         training, supervision, data        understand costs of prevention
   Healthcare provider interviews                information and how              activities                   analysis, and interpretation      Community partners learn more about per-
   Supervisor interviews                         to get it                                                                                        spectives of workers and healthcare providers
   Surveys with workers                                                                                                                          All partners understand challenges to
                                                                                                                                                  implementing basic changes and facilities
                                                                                                                                                 Community partners learn survey research skills
Creation of a community advisory                Partners agree that              Partners cooperatively       Partners hold meetings and         Project extends its reach and effectiveness
 committee                                       extended power base              select partners and          cooperatively present
                                                 is needed                        set up meetings              findings
aThis   table is an adaptation of the community participation model by Arcury et al. (28).



466                                                                                                        VOLUME   109 | SUPPLEMENT 3 | June 2001 • Environmental Health Perspectives
                                                                                                        A community-based social marketing project


    Community-based research has been                    the elaboration of major roles in the grant    Without collaboration the ability to broaden
accomplished by the TAS project through a                proposal. Role definitions for each project     the base of potential target audiences may
commitment by all partners to share all infor-           activity changed somewhat, so establish-       have been impossible.
mation, power, and decision making. Social               ing confidence in new roles took time and           Each new phase of research and interven-
marketing’s behavioral orientation has                   communication                                  tion, however, brings new challenges. As the
encouraged program planners to set behav-           • Concerns by the community group that              TAS project enters its intervention phase, we
ioral objectives and design strategies that              academic researchers may not want to           are alert to issues involving a shift of focus
address the critical factors that determine the          challenge the status quo (21) or confront      and competing opinions about the interven-
audience’s adoption of target behaviors.                 the structural causes of pesticide exposure    tions that will work best. The next stages of
Through extensive formative research, com-          • Periodic fatigue by community partners,           collaboration will focus on developing a uni-
munity partners who do not have time or                  especially with the tedious survey devel-      fied vision of an intervention that will be
interest to participate more directly in the             opment and data analysis activities, and       effective and accepted by community and
planning process can still contribute to                 periodic frustration by academic partners      academic researchers as well as by members of
important program decisions.                             that research was not moving along more        the worker community at large.
     In addition to empowerment and shared               quickly.                                           The use of community-based research for
learning, the social marketing approach of               Some of these barriers were relatively easy    challenging social problems is effective, but
examining product benefits, product, price,         to resolve. For example, to overcome lan-           only when all partners accept the values and
and other factors that influence consumer           guage barriers, the project translated essential    principles of this approach and make a com-
behavior has also been valuable to this project.    documents into Spanish and Haitian Creole.          mitment to the daily demands associated with
Without the extensive qualitative and quanti-       Academic partners had to learn to avoid jar-        this work. The results of this work strengthen
tative data collection, the partners may have       gon and buzzwords and to make better use of         all parties and seem to have a multiplicative
overlooked many aspects of pesticide expo-          visual aids. Other barriers, however, required      effect on communities. Community-based
sure, such as the impact of the beliefs about       greater time and persistence to overcome.           research is an effective approach that brings
washing hands in cold or unclean water on           Regular meetings with the full team were            the voice and knowledge of the people to
washing behaviors; the importance of co-            essential not only for the communication of         problem solving through collaborative efforts.
worker influence on washing behaviors; and          roles and expectations, but also so partners
the beliefs about the importance of washing or      could discuss any frustrations or concerns                            REFERENCES AND NOTES
entering a worksite that has been sprayed too       they had about ongoing issues. During the
                                                                                                        1.    Moses M. Pesticide related health problems and farmworkers.
early, on the frequency of preventative prac-       survey, for example, team meetings were used              Am Assoc Occup Health Nurs J 37(3):115–130 (1989).
tices. All of our formative research has been       to update all partners on the activity’s            2.    Blair A, Zahm SH. Agricultural exposures and cancer. Environ
integrated to provide a comprehensive picture       progress, to encourage and support interview-             Health Perspect 103(suppl 8):205–208 (1995).
of the costs and benefits of various protective      ers, and to reassure academic partners about        3.    Simcox NJ, Fenske RA, Wolz SA, Lee I, Kalman DA. Pesticides
                                                                                                              in household dust and soil: exposure pathways for children of
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challenges associated with community-based          most intensive level of participation requires an   4.    U.S. GAO. Pesticides. Improvements Needed to Ensure the
                                                                                                              Safety of Farmworkers and their Children. GAO/RCED-00-40.
research (19). Early in the TAS project, acade-     extensive commitment of time and resources,               Washington, DC:U.S. General Accounting Office, 2000.
mic partners learned the FWAF had negative          it may not be advisable or even possible to use     5.    Ciesielski S, Loomis DP, Mims SR, Auer A. Pesticide exposure,
experiences with academic researchers on a          this approach in many public health projects.             cholinesterase depression and symptoms among North Carolina
                                                                                                              migrant farmworkers. Am J Public Health 84:446–451 (1994).
previous project, making the organization           However, the TAS partners learned it is espe-       6.    Fenske RA. Pesticide exposure assessment of workers and their
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