Abstract
In the United States, Latino farmworkers are disproportionately at risk for death from heat-related illnesses. To elicit Latino farmworker perceptions on their fluid intake and heat stress, a qualitative descriptive, community-informed research study was conducted in eastern North Carolina. A total of 28 Mexican farmworkers participated in one of 4 focus groups. Using content analysis and guided by Intersectionality theory, themes and subthemes were identified. The first theme was Absence of Protection, represented by 2 subthemes: (1a) Intense Climate Considerations; and (1b) Workplace Exploitation. The second theme, Freedom to Drink, included 2 subthemes: (2a) Distance and Distaste; and (2b) Culture of Farm Work. Farmworkers perceived extreme outdoor temperatures as the greatest workplace barrier to staying hydrated and reported water accessibility and quality issues. Farmworker fluid intake was influenced by interlocking social categories and power systems. Policy recommendations that prevent farmworker heat-related illness and promote hydration are discussed.
Introduction
Background
Environmental heat stress resulting in heat-related illness (HRI) is a disproportionately high occupational hazard for farmworkers. In the United States from 2000 to 2010, persons working in agriculture were 35 times more likely to die from HRIs than other occupations. 1 During this period, Latino agriculture workers were even more vulnerable, with a relative risk of 3.4 for HRI deaths. 1 This is a critical concern for clinicians in North Carolina (NC) as 95% of farmworkers are Latino migrant workers from Mexico and Central America. 2
North Carolina is one of the nation's leading employers of migrant and seasonal farmworkers, with about 150,000 annually. 3 The average NC farmworker logs 10 h of work per day, 6 days a week, in open crop fields without shade trees.1,4 Currently, 75% of those that fill seasonal farmworker positions in NC do not move from their permanent residence to seek farm work and/or have other sources of employment during the off-season. The other 25% are migrants and work with the H-2A visa program. 5 This program, operated by federal and state agencies, helps farmers employ foreign workers for temporary jobs, usually vacant due to harsh working conditions and a lack of interest by workers in the United States.6,7
Heat-related illnesses range from mild conditions, such as heat rashes and heat cramps, to more critical conditions, such as heat exhaustion and heatstroke. 8 Many factors increase a worker's risk of HRI, including high heat and humidity, chronic disease, thick or impermeable clothing, physical exertion, insufficient fluid intake, and lack of acclimation to the workplace climate. 9 As a result of global warming, the environmental heat stress experienced by agricultural workers is at record levels and outdoor temperatures are expected to continue to rise. In NC, 2019 was the hottest year ever recorded. 10 Thus, it is a critical time to understand the factors that influence HRI.
Many studies on the occupational health of farmworkers11–13 and farmworker HRIs14–16 in central and eastern NC have been published in the last several years, though limited information was gathered on their fluid intake practices. In 2 studies, NC farmworkers reported drinking more water as a common HRI-preventive practice, while changing the duration, intensity, or hour of day worked were uncommon.14,15 From this literature, it is unclear if employers are encouraging or limiting these HRI-preventive practices. Nonetheless, this suggests fluid intake was a critical HRI-prevention practice among NC farmworkers.
The Occupational Safety and Health Administration's (OSHA) provides 3 vital strategies to protect workers from HRI with its “Water. Rest Shade.” campaign. 17 Specifically, these strategies include adequate water intake, periodic rest from work, and breaks in shaded areas. While at work, farmworkers reported not drinking water due to various social and occupational barriers. According to Lam et al 18 farmworkers in the state of Washington perceived workplace barriers to fluid intake as (a) short or no breaks; (b) long distance to bathroom facilities, (c) poor quality drinking water, and (d) poor employer–employee relationships.
Micro, Macro, and Intersectionality
Health disparities in HRI risk and fluid intake exist among Latinos in the United States.19,20 To design interventions that truly address the fundamental causes of health inequalities, practitioners should not narrow in on the effects of microlevel factors (individual behaviors) on health but instead aim to understand how micro- and macro-level factors (social-structural) maintain or produce inequalities. 21 Fluid intake is a complex and dynamic behavior, influenced by micro- and macro-level factors, so both should be considered together in addressing hydration and fluid intake. 22
The use of Intersectionality theory,23,24 as an analytic framework, is useful to evaluate both micro- and macro-level factors and systems of power. 25 The theory emphasizes the intersection and interplay of individual identities, especially historically oppressed identities, which shape human experience. 21 The theory was originally developed to highlight how race and gender interplayed in the violence and employment of Black women. 26
The application of Intersectionality theory has also been expanded to advance the knowledge of privilege and oppression in the workplace of various social groups. 27 Farmworkers face oppression in the workplace, from their ethnicity, nationality, and limited English proficiency; therefore, the use of Intersectional theory would further illuminate their circumstances. Intersectionality theory's 6 core concepts: inequality, relationality, power, social context, complexity, and social justice 23 are highly relevant to the vulnerability of Latino farmworkers as a power imbalance exists in their workplace, which creates complex effects on self-care behaviors, such as drinking water.
Within the macro-level, Collins 28 (p.14) explains that power systems “catalyze social formations of complex social inequalities that are organized via unequal material realities and distinctive social experiences for people who live within them.” This authority or capacity to control others could be facilitated through economic and political entities. Specific to farmworkers, the economic power systems that shape their fluid intake experiences include labor standards and payment practices, and political systems’ regulations and guidelines.
Microlevel factors that influence farmworker fluid intake include individual social identities and cultural practices of workers. One cultural practice among some people with Latino or Hispanic heritage is the consumption of certain foods and beverages to create a temperate balance within the body, known as hot-cold classification.29,30 Within this humoral practice, an overheated state is understood to put the body at risk for illness. Although farmworkers in Washington state reported knowing water was a healthy choice, they also drank alcohol to quench thirst and caffeine to increase productivity. 18 These farmworkers also mentioned drinking water when thirsty but did not indicate if they drank water when not thirsty. The thirst mechanism is usually not strong enough to drive someone to consume the equivalent lost in sweat. When the thirst mechanism is present the body is already in a hypohydrated state.9,31
Researchers have explored the imbalance between agribusiness power structures and farmworker agency, including employer-to-farmworker discrimination. Some findings indicate that this power imbalance can hinder farmworker self-care decisions.32,33 One study of California farmworkers found that trade-offs were made between maintaining a strong work ethic, productivity, lost pay, and self-care. 33 They wanted to be viewed as “good workers” to please the employer in hopes of being asked to return to work the following day or season. A recent qualitative descriptive pilot study with farmworkers in eastern NC also found power imbalances between the employer and worker in the form of employer-controlled breaks and fluid consumption. 34
To understand how migrant farmworkers can gain the health and safety protections necessary to do their work safely and stay healthy, we need to understand the intersection of their identities within the structures that impose and reinforce their oppression. To be a farmworker is to work in a sector that excludes those with that identity from several workplace protections. Farmworkers, compared to other workers, are noticeably exempt from occupational health policies and standards set forth by federal and state agencies, a doctrine referred to as agricultural exceptionalism. 35 These policies keep farmworkers uninformed and deprived of protections such as minimum wage, overtime pay, collective bargaining, and occupational safety and health.35,36 Further, NC lacks HRI occupational safety and health regulations. 37 There is no federal heat standard, but as of October 2021, OSHA initiated the process to develop one. 38 Although OSHA standards can take as long as 10 years before becoming regulation. 39
This article describes the first phase of a larger study. Since no known studies have specifically focused on NC farmworker hydration status or fluid intake, the purpose of the larger study was to explore how culture, place, and environmental heat stress influenced fluid intake and hydration status among a subset of Latino farmworkers living in eastern NC. The first phase focused on farmworker perceptions of fluid intake and the specific research questions were: (1) How do cultural beliefs, values, and norms influence farmworker agency and fluid intake? (2) How does the work environment influence farmworkers’ fluid intake? (3) What accounts for on-the-job knowledge, behaviors, and attitudes of fluid intake during environmental heat stress?
Methods
Design
We conducted a community-informed qualitative descriptive study using focus groups. The study was conducted in 2020 with partners at one Federally Qualified Health Center (FQHC). The FQHC provided health services to an area with 2300 farmworkers during peak harvest.2,7 A community-informed design was chosen to engage community members in the research process which could lead to improved health and reduced health inequities. 40 The research team was composed of the principal investigator (PI), 2 Latino FQHC staff, and a bilingual undergraduate nursing student with a Hispanic Studies minor. Thus, etic-emic perspectives, defined as researcher–participant viewpoints, aided in creating a new understanding of the phenomenon of interest. 40 Focus group discussions (FGDs) were sought to provide insight into diverse opinions and behavioral norms and permit a power shift from investigator to participants, foregrounding the voices of participants. 41 The university review board approved all study procedures, including a COVID-19 pandemic safety plan.
Participants
The study team first sought permission from local farmers to recruit farmworkers for the study. Four of the 10 farmers were allowed access to their farms for recruitment. Over 4 weeks, on different evenings following the workday, the study team drove to each of the 4 farmworker camps, shared a bilingual research-specific flyer, and obtained signed informed consent from interested farmworkers. An a priori sample size of 24 to 60 was based on a moderately high information power. 42
We invited 32 farmworkers, and all agreed to participate in the study. Inclusion criteria were Latino men and women between ages 18 and 54, who spoke English or Spanish, worked primarily outdoors (>50%) 8 or more hours per week, with no self-reported history of recent illness, kidney disease, use of diuretics, or current pregnancy. Of the 4 that agreed and did not participate, one was ineligible due to age criteria and 3 were busy when the FGDs were held.
The final sample included 28 farmworkers; all were males, migrants from Mexico, and between the ages of 23 and 53 (see Table 1). The specific location of participants’ homes in Mexico was not asked, but the FQHC staff believed most farmworkers to be from Durango and other states in central Mexico, representative of the typical farmworker migration pattern to this area of eastern NC. All participants worked with the H-2A visa program with a range of farm work experience from 4 to 26 years. All had been in NC for at least 2 weeks at the time of data collection; therefore, assumed to be acclimated to the climate. 9 The current crops in which participants worked were tobacco, sweet potatoes, cotton, and cucumbers. Although working in NC, they labored and lived in 3 of the poorest counties in the state, with 20% to 24% poverty rates.43,44
Focus Group Participant Profile (4 Focus Groups: N = 28 Participants).
Abbreviation: FG = Focus Group.
Demographic data missing from one participant.
Data Collection
The study was conducted on farmworker camps in eastern NC during July and August of 2020, the hottest months of the year in NC. During 2020, eastern NC experienced 29 days above 32 °C (90 °F) in July and 16 in August. 45 Four FGDs were held on 4 different dates, between noon and 8 o’clock in the evening, with participants gathered outside in shaded areas. Prior to beginning the focus groups, informed consent was reviewed, and participant confidentiality was reinforced. One moderator (first author and PI) and one bilingual co-moderator (FQHC staff or the student) facilitated each group. A semistructured interview guide based on farmworker fluid intake literature, pilot study, and study objectives, was developed, and translated from English to Spanish. Most of the interview guide questions asked about effects on fluid intake from the farmworkers’ intersectional identities (migrant, Spanish-speaking, rural) or the conditions that impact their identities (workplace authority, agency, cultural norms). The questions were pilot tested and revised with feedback from one Latino research team member. Focus groups were conducted in Spanish, per participant preference, and discussions were audio-recorded with their permission. The 4 FGDs were held for 39 to 66 min, with an average time of 56 min. At the conclusion of each, a summary was read aloud and participants either confirmed or clarified items. At the beginning or at the end of the FGD, participants completed a demographic survey, labeled with a unique ID number. Social and demographic factors included in the survey were questions of age, gender, ethnicity, country of birth, and H-2A status. These were particularly important for a study guided by Intersectionality theory as we aimed to understand how these identities influenced hydration. After the FGD, participants received a 25-dollar incentive.
Data Analysis
In keeping with a community-informed approach, all study team members were engaged in data analyses and interpretation. Whole transcripts were selected as the unit of analysis. Audio recordings and notes were translated and transcribed into English within 2 weeks following each focus group. Naturalized transcripts were prepared jointly by the research team members and validated for accuracy. 46 Beginning with the first focus group transcript, the PI read the transcripts multiple times, taking care that each transcript was reviewed with a similar frequency.
A codebook was generated following biweekly discussions between the PI and a nursing faculty with qualitative research and Latino population health expertise (second author). First-level coding included in vivo and descriptive coding, which occurred through an iterative process. 47 In vivo coding moved to descriptive coding in some cases. For example, “Stomach doesn't feel very good, when you drink something cold, walking, working in the heat” was descriptively coded as Hot/Cold Balance. Next, a matrix was created to align with each research question and matched with the research concepts. Finally, concepts from Intersectionality theory were compiled into a case-by-variable matrix to compare the frequency of the codes within each FGD transcript.
To explore the “explicit and covert meanings” in the transcripts, content analysis was employed. 48 (p.243) We started with a set of pre-identified concepts (deductive coding), including concepts from Intersectionality theory and the pilot study. Although coding for Intersectionality theory, the interrater reliability was 86%. 49 Then we expanded on them to include other concepts that were identified during the inductive coding process. 50 Four focus groups were sufficient to reach 95% code saturation using procedures outlined by Hennink and colleagues. 51 An audit trail was maintained through research logs, field notes, memos, and reflective notes.
Results
The 2 themes identified were (1) Absence of Protection and (2) Freedom to Drink. The first theme, Absence of Protection, was represented by 2 subthemes; (a) Intense Climate Considerations; and (b) Workplace Exploitation. The second theme, Freedom to Drink, was represented by 2 subthemes; (a) Distance and Distaste; and (b) Culture of Farm Work.
Absence of Protection
The theme, Absence of Protection, described the inadequate health standards and norms of the agricultural industry experienced by farmworkers. Farmworkers worked in extreme environmental heat with few breaks and long hours. The farmworkers described inconsistent occupational policy compliance and payment practices.
Intense climate considerations
The workplace climate was described by farmworkers as hot and humid with frequent exposures to harmful chemicals. They had limited personal knowledge and workplace safety practices regarding heat stress prevention. One participant noted “No there's not any rules for consuming water. Just whenever you need some you are going to consume. Being the climate how it is, no matter.” Participants were rarely allowed longer or more frequent breaks during periods of extreme heat. Participants from one focus group recalled leaving the field due to extreme heat once during the 2020 season. More ice or more water was reported as common aids on extremely hot days. The only participant with a university education mentioned OSHA by name and compared Virginia's rules to other states as more “distinct.” None expressed any awareness or understanding about federal regulations regarding environmental heat stress or climate change policy.
Environmental heat stress was consistently perceived as the greatest factor affecting farmworker fluid intake decisions and a barrier to staying hydrated at work, across all 4 focus groups. Extreme heat was frequently experienced, both outdoors in the fields and inside tobacco barns. One participant stated, “the heat does a lot of damage and at night you have nightmares.” This was confirmed by another participant, “yes, dreams, nightmares (sueños, pesadillas).” Days were described as “super-hot (super caliente),” and farmworkers recognized that they had to drink more water at work than other workers.
Farmworkers reported other adverse occupational health exposures or “damages,” such as humidity, nicotine, and pesticides. They spoke of their “fight” against these exposures that “attack” them daily. The humidity from the ground, off the crops, and after it rains caused greater thirst among farmworkers. Participants explained that the tobacco plants let off heat and the height of the plant blocked any cooling effects of the wind, which increased their need for water. They had “to take care to not drink water with dirty hands because if we drink the water with dirty hands, the chemicals can make us sick (mareado) or vomit.”
Workplace exploitation
We interpreted workplace exploitation as any imbalance of power between the employer or agribusiness and the employee that fostered inequality, negatively affecting worker safety or wages. Minimal health education on HRI, the agribusiness payment system, and negative experiences with previous employers were examples of workplace exploitation among the Mexican migrant farmworkers in this study. However, when directly asked, participants rarely complained about their job or workplace conditions. One or more participants in each group reported “everything is peaceful,” and “we are very comfortable here.”
Farmworkers reported outdated and incomplete education from their employer. Farmworkers shared how they were shown the same 3-h occupational education video every year. One worker believed it was the same video he had seen for 20 years. They recalled the video indicating to drink “when they are thirsty” and “to have water nearby” but did not specify a frequency or quantity of water to drink. Further, farmworkers could not recall the video describing physiologic indicators or consequences of dehydration. Farmworker personal knowledge on how water and beverage intake affect the body was limited and varied. Some reported “kidney pain” while working and felt drinking sodas helped their kidney pain while some felt sodas worsened the pain. One group agreed that 2 liters of water per day is the recommended amount during hot days while another could explain how urine color darkened as a person became more dehydrated.
The agribusiness practice of a “piece-rate” payment system compensates farmworkers by the pieces picked in a shift, incentivizing faster work.
52
Although harvesting sweet potatoes, farmworkers reported being paid 50 cents per filled 35-pound bucket. This payment system encouraged farmworkers to take fewer breaks. And as one farmworker explained, “to not lose time, you also harm the body, to fill more buckets.” Farmworkers also drank less water when working in sweet potatoes. One farmworker admitted: You can't [drink a lot of water] because you won't be able to bend over as much. When it's time to stop you take a little sip and that's it because if not and you fill yourself up you feel like it will come out your nostrils. Focus Group Number One (FG #1)
Regarding specific crops, farmworkers agreed with one's description of work in sweet potatoes as “cool[er] but fast work” and work in tobacco as “hot[ter] but slow work.”
Farmworkers expressed a history of negative experiences with previous employers. They reported that individuals or groups would be fired if they complained or didn't work hard. Others reported past experiences of asking people living near their workplace for water since there was none at work or it was inaccessible. Participants described past employers as “racist” and one “didn't care if any of us drank water at all, he wanted his earnings to stretch.” Participants also reported labor violations of their H-2A program work contract. These included reports of not receiving reimbursement for travel from their home location (ie, Mexico) and reports of not receiving the number of hours of employment stipulated by their contract. The workers did not explain if this was because there was not enough work for them or if the employer was scheduling the work in a way to reduce labor costs.
Intersectionality theory's concepts of inequality, relationality, and power were linked to the study theme Absence of Protection, with power being the most prominent concept. Within the Workplace Exploitation subtheme findings, systems of power noted relevant to farmworker fluid intake included economic systems influencing farmer and farmworker income; migration systems creating power imbalance between employer and migrant employee; and political systems controlling policy. The farmworker identities found to have an impact on their fluid intake overlapped and included migrant, lower economic status, and employee. Intersectionality theory's concept of inequality was prominent within the subtheme of Intense Climate Considerations. Farmworkers are exposed to more occupational hazards and are protected less due to the existence of agricultural exceptionalism and lack of HRI protections.
Freedom to Drink
The second theme, Freedom to Drink, described the contradictions farmworkers perceived in their freedom to drink water despite water accessibility issues. Some farmworkers stated, “we are never in need for water at work” and at the same time reported that water was available but could be far away from their current location. Approximately half of the farmworkers reported poor water quality stemming from the geographical location and plumbing of the farmworker housing.
Distance and distaste
Some farmworkers perceived always having enough water at work. One participant noted “No matter the type of work we are doing, he [his employer] always goes back to get [us] water. As soon as you’re out, he goes and gets water, you are never without water.” Farmworkers reported drinking between 1 and 6 liters (average 3 liters) per day, drinking every 10 to 60 min (average every 15 min). Some believed drinking water at work helped them feel healthy while one participant noted when he doesn't drink water at work; “I return to home and I feel fatigued, I go to the bathroom and it's hard.”
Despite farmworkers perceptions of ample water quantity, water was reported to be far away from the worksite, or they choose to purchase and consume beverages other than water. Water was regularly stored in large orange water coolers at the end of long crop rows or in vehicles parked at the edge of fields. Farmworkers usually did not bring water bottles with them into the field. They chose to do this because of the risk of contaminating their water with pesticides or other chemicals from the crops. One farmworker explained: We have to take care to not drink water with dirty hands because … the chemicals can make us sick (mareado) or vomit. Sometimes we have to take a swallow, then spit it out, now we can drink it. The dust of the chemical gathers here around the mouth. Focus Group Number Four (FG#4)
Distance to the stored water was compounded by infrequent and irregular employer-permitted breaks. Farmworkers reported being allowed 3 employer-permitted breaks, over an 8 to 12-h workday: a morning and afternoon break lasting from 5 to 15 min and a 30-min lunch break. To compensate for short, infrequent breaks, farmworkers gulped water quickly to maintain hydration. As a result of gulping water, farmworkers experienced adverse gastrointestinal symptoms such as pain and nausea, which decreased their desire to drink. One farmworker explained, “and even though your stomach is full of water, your mouth gets really dry, and you still want to go drink more water, even though you feel full.” Although employer-permitted breaks were infrequent, farmworkers felt they could quickly take unscheduled breaks to drink water and then return to work. A worker stated, “even if we are not finished in the row” or “are [on] top of a machine … you can stop and go get water.” The farmworkers did not feel pressured to only drink during the scheduled breaks.
Farmworkers reported the water at the worksite or where they lived had poor taste or appearance. Specifically, they reported the appearance of water being yellow or moldy (a moho). Some chose to buy bottled water instead of drinking the water at work, especially if the water was from a well, and remarked that the water in eastern NC to be worse than in other states where they had worked.
While working in NC, farmworkers reported greater availability and accessibility to beverages compared to their native home. Due to a higher income in the United States, farmworkers bought more soda, sports drinks, and beer; “a lot of things we consume here, we don't there [Mexico] like Monster® [energy drinks] and Gatorade®.” Sodas, especially Coca-Cola®, were preferred to water, due to the taste. Some drank beer at the end of the day, to help with pain from sore muscles accrued during work and to help them sleep.
Most farmworkers reported humoral practices. Farmworkers preferred cool water to ice water or warm water. While working in the heat, farmworkers indicated they would not drink ice water because of the potential for bodily pain or a “heat shock (choque de calor).”
Culture of farm work
Field notes and farmworker perceptions confirmed poor farmworker living conditions. Specifically, participants were concerned about the lack of air-conditioning, and the older age of the homes, including the home's plumbing. One participant compared his current housing to previous; “there is air conditioning, there are sufficient bathrooms. This is a good place for us. There are places that are worse, there are trailers (mobile homes), no air conditioning, a bathroom for 5 to 6 people.” Mobile homes, compared to houses, were perceived as hotter, and the farmworkers felt more water intake was necessary inside these structures to stay hydrated. Farmworker camps were within 15 min of convenience stores and despite not having consistent transportation, the rural location of the camps was not perceived as a barrier to fluid intake. Language differences between the employer (predominately English-only) and the farmworkers (predominately Spanish-only) were also not perceived to hinder fluid intake. Five to 6 farmworkers lived in one mobile home or 8 farmworkers lived in a small house. Farmworkers reported that the portable bathrooms in the fields were either too hot or too unsanitary to use. One portable bathroom was noted about 250 yards from one worksite.
Social context, another concept of Intersectionality theory, was prominent within the theme of Freedom to Drink. The fluid intake of farmworkers could vary greatly depending on their social context, particularly the area's climate and water quality, access to beverages, and workplace culture. The Distance and Distaste, and the Culture of Farm Work subthemes align with the social justice concept in the farmworkers’ poor water quality, water access, employer-provided housing, and sanitation.
Discussion
This qualitative descriptive study provided a greater understanding of the participating farmworkers’ perceptions on their fluid intake, specifically water, and how macro-level factors influence farmworker hydration behaviors. Environmental heat stress was consistently perceived as the greatest factor affecting farmworker fluid intake decisions and a barrier to staying hydrated at work. Farmworkers did not directly express powerlessness specific to their water intake, although barriers to fluid intake were uncovered which surfaced as self-care sacrifices to meet workplace demands, incomplete hydration education, and water accessibility and water quality issues. The influence of workplace culture on fluid intake included poor housing and bathrooms.
Framed by Intersectionality theory, this study suggests fluid intake, mediated through work, intersects with multiple interlocking social categories and power systems. We found expressions of a power imbalance between these migrant farmworkers and the employers. The power imbalance was reinforced by the government exclusions of these workplaces from health and safety regulations that are required of other industrial sectors. Structural discrimination intersects with the farmworkers’ social positions in class and citizenship to shape the exploitation of these workers, their exposure to excessive heat, and their lack of protection from HRIs.
Occupational regulations that assure water, rest, and shade practices are lacking. Most concerning are the short and infrequent breaks that farmworkers receive, as they work many hours a day, outside, in intense heat. Breaks during the workday should allow farmworkers to rest, hydrate and use the bathroom, core behaviors in OSHA's ‘Water. Rest Shade.’ campaign. This campaign and HRI-prevention regulations can protect workers against HRI. Vega-Arroyo et al 53 conducted a study with 259 California farmworkers and despite data collection during a summer season, no participants reported HRI symptoms. The authors suggested that California HRI-prevention regulations, implemented by the study farms, protected the workers.
Congruent with this study, participants in the Vega-Arroyo et al 53 study perceived freedom to drink throughout the workday. However, this was not consistently expressed across the nation. Farmworkers in Washington state reported water consumption limited to breaks or the end of the workday and many Oregon and Washington farmworkers had only one 30-min break per shift.18,19
California, 54 Minnesota, 55 Washington, 56 and recently Maryland 57 are the only states with HRI-prevention regulations. California's heat illness prevention law is the most comprehensive and requires employers to (a) train all employees and supervisors about heat illness prevention; (b) allow and encourage employees to drink at least one quart of water per hour; (c) provide shade for cool-down breaks; and (d) establish a written heat stress prevention plan. In addition, if temperatures are above 35 °C (95 °F), workers must be allowed 10-min paid breaks every 2 h. Minnesota's standard only protects workers against extreme indoor temperatures.
Not only are occupational policies lacking but our study also indicated that some occupational hydration policies are poorly enforced. Under OSHA's Occupational Safety and Health Standards for Agriculture, subpart 1928.110, agricultural employers, with eleven employees or more, are required to provide a sufficient quantity of water in a readily accessible area. 58 Although participants reported that employers provided sufficient quantities of water, it was not always accessible. Individual backpack-mounted water bladders could improve farmworker access to water. During a study with cane workers in El Salvador, self-reported water consumption increased after the provision of water bladders, portable canopies for shade, and scheduled rest periods. 59 Despite this, authors advised that the interventions were costly, time-consuming and would require stakeholder commitment to be successful.
The most recent recommended standard from the National Institute for Occupational Safety and Health (NIOSH) 9 states that workers should drink one cup of cool water every 15 min while working, equaling half of a quart to one quart per hour, depending on the wet bulb globe temperature (WBGT) index and workload. Although the farmworkers in this study were not aware of the NIOSH standard, they did report drinking as often as the standard recommended. So, it is unclear why they also reported the need to gulp water or drink large amounts of water at once. It is possible farmworkers are overestimating their intake frequency or providing a socially acceptable answer. Arnold et al 60 have reported that adolescent farmworkers (n = 30) in NC also reported stomach pains and shortness of breath after gulping water and as a result, limited or avoided water intake. Gulping water could suggest farmworkers need alternate means, besides fluid intake, for cooling their bodies during times of high heat, such as longer breaks in shaded areas.
Further demonstrating the existence of power systems influencing farmworker fluid intake, the “good worker” trait 33 resulted in neglect of self-care by the farmworkers in this study. The observation that farmworkers rarely complained about their situation (living or working) suggests that farmworkers were not fully aware of the standards or they went along with lack of standards, to appease or keep their employment. Like farmworkers in Wadsworth et al 33 and Lam et al 18 farmworkers in this study avoided drinking more water and taking bathroom breaks because they would receive less pay, and possibly for fear of jeopardizing their “good worker” positionality.
The presence of the “good worker” trait in many NC farmworkers was verified by the Latino members of the research team. The team members further explained that the COVID-19 pandemic may have exacerbated the “good worker” trait and potential for exploitation as farmworkers were even more grateful to be employed in the study year than in past years. Scholars report that Latino migrant workers are more vulnerable to exploitation than other workers. Termed superexploitation, scholars describe how Latino migrants will work harder for less pay and are less likely to challenge authority.52,61 In Mexico, agriculture workers earn the equivalent of 10 to 16 dollars per day, while farmworkers in the United States earn that amount per hour.7,62
The H-2A visa program requires that employers pay for housing for all H-2A farmworkers and that the housing must meet US Department of Labor (DOL) safety standards, including water and sanitation standards. Housing was a fluid intake barrier for the farmworkers in our study, all H-2A workers. In particular, they were concerned about the quality of drinking water coming from the faucets within the homes. The Migrant Housing Act of NC 63 requires inspection of farmworker housing and enforcement of water quality and water sanitation standards. Bischoff et al 64 from a report published in 2012, found 31% of sampled water from camps with H-2A workers failed the Total Coliform Rule, failing to meet NC DOL standards. The existing regulations at the time did not ensure water safety requirements and is concerning because the percent of farmworkers in the H-2A visa program in the United States and NC is increasing, suggesting the H-2A program is a growing agribusiness practice.
Our findings contribute to a national social justice concern that many communities in rural America have unsafe drinking water. The participants noticed that water in rural, eastern NC tasted worse than other areas of the United States. Further, the program director of the FQHC admitted that many citizens in the study area do not drink tap water, but rather purchase bottled water for drinking. According to 2 US studies of water-quality measures with data spanning 30 years and most states, water quality improved as areas become more urban.65,66 From 2010 to 2015, 10% of rural samples had at least one annual contaminant mean concentration greater than the recommended limit, while only 5% of urban setting samples exceeded the limit. 66 This equates to millions of Americans exposed to unhealthy drinking water. 65 Small community water systems in rural towns are struggling to provide clean water to their citizens due to poor regulation of environmental pollutants, shrinking populations, and aging infrastructure with fewer financial resources to implement infrastructure upgrades.65,67
Two unique study findings were the physical complaints from gulping water to maintain hydration, and the identification of the microclimates within the tobacco crop that increased the need for water consumption. Tall, dense crops, like tobacco, can block the wind, which decreases evaporation speed; thereby, increasing heat stress.9,68 Although most farmworker studies estimate environmental heat stress through regional weather station measurements, authors from 2 US studies have reported microclimate (the area immediately surrounding the worker) measurements experienced by the farmworker. Set in Florida 69 and in California, 70 the study participants were not working in tobacco fields at the time of data collection.
Limitations
Due to the COVID-19 pandemic during the summer of 2020, data collection was delayed and shortened. We intended to include perspectives from both men and women and migrant and seasonal workers; however, our sample was limited to male migrant farmworkers working with the H-2A visa program. Female farmworkers did not live in the camps we were able to study. The convenience sample of farmworkers was from one geographic region of the state; thus, findings could only be transferrable to a similar region of the country. Sample bias was likely due to the limitation of farmer permission, a commonly reported study limitation by authors of Latino farmworker studies.71–73
Conclusion and Implications for Policy and Research
Farmworkers are essential workers, both as contributors to the NC's top industry and for maintaining the food production and distribution process to US households. Occupational health policies inadequately protect farmworkers from HRIs and likely other acute and chronic diseases. Health care professionals can advocate for the passage of state-level HRI prevention policies like those in California. Regular and accurate educational forums for farmworkers are recommended to stress the importance of HRI prevention. Any interventions to prevent HRI and promote fluid intake will need to consider Latino farmworkers’ economic vulnerabilities and their hesitance to speak out about occupational health hazards. Improvements to the H-2A program, public water systems, and the farmworker–employer relationship could also prove beneficial. More research is needed on how housing and work visa status affect farmworker fluid intake, especially among non-H-2A workers. By combining observation and physiological measurements of HRI and hydration status, especially within the worker microclimate, researchers can further understand fluid intake behaviors and hydration among farmworkers.
Climate change has been described as the greatest public health threat of this century and is predicted to have dramatic human health impacts, from disease related to poor water quality and supply, injury from more frequent extreme weather events, increased spread of infectious disease to complications of chronic disease.74,75 Farmworkers are on “the front lines of climate change,” according to researchers Kearney and Garzon. 76 (p.311) All policymakers should recognize the increased HRI risk for farmworkers and strengthen laws to protect these workers.
Footnotes
Acknowledgments
The authors want to first thank the participants for their contribution to this study. The authors appreciate the partnership of the FQHC staff, especially Brayan Madero and Vanessa Viridiana Hernandez, during all phases of the study. The authors thank Dr Charleen McNeill, Dr Linda Bolin, and Dr Greg Kearney for their contributions to the study design and Brianna Foster, RN for her contribution to data acquisition.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the East Carolina University College of Nursing Office of Research and Scholarship, Beta Nu Chapter of Sigma Theta Tau International Honor Society, East Carolina University College of Nursing, (Doctoral Student Research Grant).
