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For over three decades, tree care workers in the United States have experienced disproportionately high rates of fatal injuries. While the types of fatalities have been well documented, few studies have used a qualitative approach to examine underlying circumstances and other contributing risk factors. In this study, a total of 69 investigative fatal injury reports spanning from 1987 to 2023 from the National Institute of Occupational Safety and Health (NIOSH) were reviewed and assessed. Overall, most fatal work incidents resulted from falls from trees, being struck by tree sections or branches, being caught, or dragged into equipment (e.g., woodchippers, stump grinders), and electrocutions. Over 23.0% of decedents had been on the job one year or less at the time of death. An estimated 58.0% of employers lacked a safety plan, and only 39.1% provided job training to employees. Recurring safety assessment recommendations stressed that employers and workers conduct thorough job hazard assessments, provide proper training, and develop and implement a work safety plan. These findings support current initiatives to implement public health policy action to protect tree care workers. Additional safety measures must be considered for new and vulnerable workers, before actively performing tree care work. The persistent occurrences of these fatal incidents demand a call to action, necessitating the adoption of a national policy that establishes uniform safety standards and mandates comprehensive training. Implementing these decisive measures will not only protect workers but also reduce costly accidents and insurance premiums, decrease lost productivity, and promote a culture of safety within the industry.

Globally rising antibiotic-resistant (AR) and multi-drug resistant (MDR) bacterial infections are of public health concern due to treatment failure with current antibiotics. Enterobacteria, particularly Escherichia coli, cause infections of surgical wound, bloodstream, and urinary tract, including pneumonia and sepsis. Herein, we tested in vitro antibacterial efficacy, mode of action (MoA), and safety of novel amino-functionalized silver nanoparticles (NH 2 -AgNP) against the AR bacteria. Two AR E. coli strains (i.e., ampicillin- and kanamycin-resistant E. coli), including a susceptible strain of E. coli DH5α, were tested for susceptibility to NH 2 -AgNP using Kirby-Bauer disk diffusion and standard growth assays. Dynamic light scattering (DLS) was used to determine cell debris and relative conductance was used as a measure of cell leakage, and results were confirmed with transmission electron microscopy (TEM). Multiple oxidative stress assays were used for in vitro safety evaluation of NH 2 -AgNP in human lung epithelial cells. Results showed that ampicillin and kanamycin did not inhibit growth in either AR bacterial strain with doses up to 160 μg/mL tested. NH 2 -AgNP exhibited broad-spectrum bactericidal activity, inhibiting the growth of all three bacterial strains at doses ≥1 μg/mL. DLS and TEM revealed cell debris formation and cell leakage upon NH 2 -AgNP treatment, suggesting two possible MoAs: electrostatic interactions followed by cell wall damage. Safety evaluation revealed NH 2 -AgNP as noncytotoxic and antioxidative to human lung epithelial cells. Taken together, these results suggest that NH 2 -AgNP may serve as an effective and safer bactericidal therapy against AR bacterial infections compared to common antibiotics., Competing Interests: Declaration of competing interest There is no conflict of interest to disclose., (Copyright © 2024 Elsevier B.V. All rights reserved.)

The coronavirus disease 2019 (COVID-19) is a respiratory disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), but whether the asthmatic patients are at increased risk for severe COVID-19 illness than non-asthmatic patients has remained unclear. This scoping review aimed to assess the available evidence to determine if asthmatic patients are at a higher risk for severe COVID-19 illness. Searching several electronic databases and adhering to the PRISMA guidelines, we conducted a scoping review of 70 articles and using defined inclusion-exclusion criteria, 21 articles were analyzed in-depth and included in this scoping review. The findings of this scoping review point to a lack of relationship between asthma and severe COVID-19 illness. While a limited number of studies (n = 4) identified asthma as a risk factor, most studies (n = 17) found no independent association between asthma and severe COVID-19 illness. We, thus, conclude that asthma may not be a potential risk factor for severe COVID-19 illness. Owing to limited evidence, we recommend large-scale prospective cohort studies with standardized methodologies to decipher potential role of asthma in COVID-19 severity. Further, understanding the impact of specific asthma medications, genetic factors, and other comorbidities on COVID-19 outcomes may help inform clinical practice guidelines for effective patient health management., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Arguably the most ecologically and economically valuable pollinators worldwide, honey bees play a significant role in food production and enrich biodiversity through pollination. Varroa destructor is an invasive ectoparasitic mite that attacks and feeds on European honey bee, Apis mellifera. Because literature on the effectiveness and sustainability of various treatment modalities available for Varroa mite control in honey bee colonies are scattered, this scoping review was conducted to serve as a guiding document with a focus on: (1) identifying the detrimental impact Varroa mites have on the European honey bee; (2) determining current methods for Varroa mite control and their limitations; (3) examining current market landscape and key players in the pesticide market; and (4) identifying opportunities for more sustainable Varroa mite control methods. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, 397 articles published between 1998 and 2022 were screened; of which 65 articles were retained using inclusion/exclusion criteria, which were systematically analyzed in-depth, information extracted, and included in this scoping review. The results suggest that Varroa mites are one of the predominant causes of global honey bee decline as they lack natural resistance to Varroa mites, thereby negatively affecting honey bee reproduction and immunity, killing broods, and transmitting pathogenic viruses to colonies. Further, our findings suggest that: apiarists have many options for Varroa control, but no method has proven to be effective, safe and nonpersistent in the environment; adoption of nano-pesticides and development of sustainable alternatives to traditional pesticides are key drivers for growing pesticide market; and nano-pesticides may have potential to serve as an effective, safe and non-ecopersistent pesticide for Varroa mite and associated virus control. In conclusion, this review highlights an unmet need for effective and sustainable control strategies and tools for Varroa mite and virus control., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objectives: Ideally, mosquito control programs (MCPs) use surveillance to target control measures to potentially dangerous mosquito populations. In North Carolina (NC), where there is limited financial support for mosquito control, communities may suffer from mosquito-related issues post-hurricane due to lack of existing MCPs. Here, study objectives were to (1) investigate the emergency response of a subset of NC counties post-Hurricane Florence and (2) develop guidelines and policy recommendations to assist MCPs in post-hurricane mosquito control response., Methods: A survey was administered to a subset of eastern NC counties (an area previously impacted by hurricanes) with various levels of MCPs (from none to well-developed)., Results: All respondents indicated that having Federal Emergency Management Agency (FEMA) training would be helpful in developing a post-hurricane emergency response plan for mosquito control. There was concern related to a lack of knowledge of emergency control methods (eg, aerial/ground, adulticiding/larviciding) post-hurricane. MCP structure (eg, infrastructure, resources, operational plans/policies) could facilitate response activities and help ensure necessary emergency financial support from agencies such as FEMA., Conclusions: Mosquito control post-hurricane protects public health. Public health and other agencies can be networking resources for MCPs. Policy recommendations include implementation of routine FEMA assistance training workshops to improve an understanding of processes involved in assistance and reimbursement.

Background: In 2019, grounds maintenance work was ranked among the most dangerous jobs in the United States. The objective of this study was to provide a national profile of fatal injuries of grounds maintenance workers., Methods: Data from the Census of Fatal Occupational Injuries and Current Population Survey were analyzed to determine grounds maintenance worker fatality rates and rate ratios during 2016-2020., Results: During the 5-year study period, a total of 1064 deaths, or average fatality rate of 16.64 deaths per 100,000 full-time employees (FTEs) was identified in grounds maintenance workers compared to 3.52 deaths per 100,000 FTEs for all occupational worker deaths in the United States. The incidence rate ratio was 4.72 per 100,000 FTEs [95% CI: 4.44-5.02; p < 0.0001]. The primary events or exposures that led to work-related deaths were transportation incidents (28.0%), falls (27.3%), contact with objects and equipment (22.8%), and traumatic acute exposures to harmful substances or environments (17.9%). Black or African American workers had higher death rates, while Hispanic or Latino workers accounted for over one-third of all occupational-related fatalities., Conclusions: Each year, fatal work injury rates were consistently nearly five times higher among those employed in grounds maintenance work than all US worker fatalities. Wide-ranging safety intervention and prevention measures are needed to protect workers. Future research efforts should employ methods that include qualitative approaches to gain a better understanding of worker's perspectives and employer's operational work practices to mitigate risks that contribute to these high work-related fatalities., (© 2023 The Authors. American Journal of Industrial Medicine Published by Wiley Periodicals LLC.)

Background: Agricultural workers are disproportionately at risk for heat-related morbidity and mortality. The purpose of this study was to explore how sociocultural and occupational factors, and environmental heat stress influenced fluid intake and hydration status among Latino farmworkers working in eastern North Carolina., Methods: A community-informed, mixed methods research study was conducted in partnership with staff at a federally qualified health center. In summer 2020, we recruited Latino farmworkers at migrant camps. Twenty-eight male, migrant farmworkers participated in focus group discussions and 30 completed surveys and provided urine specimens. Wet bulb globe temperatures were measured in fields where workers labored. Content analysis and parametric analyses were performed. Data integration was completed using a meta-matrix., Results: Prior to work, 46.7% of farmworkers' urine specific gravity measurements indicated dehydration, which increased to 100% after work. The farmworkers spent between 2 and 7.5 hours of their day working in conditions above the recommended limits for workplace heat exposure. Farmworkers described exposure to extreme heat and inconsistent occupational policy compliance. Farmworkers expressed the opportunity to drink water but accessibility and poor water quality limited hydration. The integrated data supported congruent findings of extreme heat, few work breaks, and substandard housing., Conclusion/application to Practice: Farmworkers are dehydrated at work, placing them at higher risk for heat-related illness (HRI). By engaging with agricultural stakeholders, occupational health nurses can combine efforts and advocate for effective health and safety work policies to reduce HRIs and deaths among farmworkers. Legislation stipulating cooling and hydration practices would support safer work environments.

The readiness of the public health workforce to deliver the essential public health services is benchmarked against training competencies. Consequently, it is expected that the establishment of the Council on Education in Public Health competencies will continue to drive the agenda of the learning continuum, from education to practice. However, the absence of environmental health as a listed competency in the Council on Education in Public Health accreditation criteria weakens the core public health program structure originally outlined by the National Academy of Medicine (formerly known as the Institute of Medicine) and could further dissolve environmental health content from schools and programs of public health. The authors have examined the literature on environmental health and public health education, and propose 3 overarching perspectives to employ from a theory, practice, and policy viewpoint to address this disconnect as follows: The current environmental health competency gap weakens the public health workforce infrastructure by creating graduates without the necessary science-based skills to protect communities from environmental threats. This departure from environmental health devalues the profession of public health and prohibits populations from reaching their full health potential. Practitioners, educators, and the public need to play a role in transforming siloes in environmental public health theory, practice, and policy into coherent learning ecosystems on which current and future populations can confidently depend., (Copyright © 2021. Published by Elsevier Inc.)

Background: The initial limited supply of COVID-19 vaccine in the U.S. presented significant allocation, distribution, and delivery challenges. Information that can assist health officials, hospital administrators and other decision makers with readily identifying who and where to target vaccine resources and efforts can improve public health response., Objective: The objective of this project was to develop a publicly available geographical information system (GIS) web mapping tool that would assist North Carolina health officials readily identify high-risk, high priority population groups and facilities in the immunization decision making process., Methods: Publicly available data were used to identify 14 key health and socio-demographic variables and 5 differing themes (social and economic status; minority status and language; housing situation; at risk population; and health status). Vaccine priority population index (VPI) scores were created by calculating a percentile rank for each variable over each N.C. Census tract. All Census tracts (N = 2,195) values were ranked from lowest to highest (0.0 to 1.0) with a non-zero population and mapped using ArcGIS., Results: The VPI tool was made publicly available (https://enchealth.org/) during the pandemic to readily assist with identifying high risk population priority areas in N.C. for the planning, distribution, and delivery of COVID-19 vaccine., Discussion: While health officials may have benefitted by using the VPI tool during the pandemic, a more formal evaluation process is needed to fully assess its usefulness, functionality, and limitations., Conclusion: When considering COVID-19 immunization efforts, the VPI tool can serve as an added component in the decision-making process., Competing Interests: Competing Interests The authors have no competing interests., (This is an Open Access article. Authors own copyright of their articles appearing in the Journal of Public Health Informatics. Readers may copy articles without permission of the copyright owner(s), as long as the author and OJPHI are acknowledged in the copy and the copy is used for educational, not-for-profit purposes.)

Competing Interests: The authors declare no conflicts of interest.

The geographic areas most impacted by COVID-19 may not remain static because public health measures/behaviors change dynamically, and the impacts of pandemic vulnerability also may vary geographically and temporally. The nature of the pandemic makes spatiotemporal methods essential to understanding the distribution of COVID-19 deaths and developing interventions. This study examines the spatiotemporal trends in COVID-19 death rates in the United States from March 2020 to May 2021 by performing an emerging hot spot analysis (EHSA). It then investigates the effects of the COVID-19 time-dependent and basic social vulnerability factors on COVID-19 death rates using geographically and temporally weighted regression (GTWR). The EHSA results demonstrate that over the three phases of the pandemic (first wave, second wave, and post-vaccine deployment), hot spots have shifted from densely populated cities and the states with a high percentage of socially vulnerable individuals to the states with relatively relaxed social distancing requirements, and then to the states with low vaccination rates. The GTWR results suggest that local infection and testing rates, social distancing interventions, and other social, environmental, and health risk factors show significant associations with COVID-19 death rates, but these associations vary over time and space. These findings can inform public health planning.

Competing Interests: The authors declare no conflict of interests.

A pilot project was conducted to evaluate the working conditions and work-related body pain among Latino immigrant tree trimmers ( n  = 57) in the commercial pine forest service industry. Participants were interviewed about personal and work characteristics, job-related occupational hazards, and body pain. A structured questionnaire and a body pain diagram were used as measures for evaluating associations between personal and work characteristics and body pain. The most common health complaints were physical exhaustion (80.7 percent) and headache (33.9 percent). The reported percent of work-related body pain was 54.4 percent. Statistically significant associations were identified between experiencing body pain in knees, working more than two years, and working more than six hours per day ( p  < .05) as a tree trimmer. Thorough clinical evaluations are needed to confirm these findings. Future research including a larger sample size and more in-depth evaluations are needed to better evaluate worker tasks, musculoskeletal risk factors, and safety climate issues among this highly vulnerable occupational group.

The aim of this study was to evaluate respiratory health problems, including suspected asthma, and healthcare provider utilization among a sample of Latinx hired child farmworkers in rural North Carolina (n = 140). In 2018, a respiratory health questionnaire and breathing tests were collected from Latinx child (11-19 years) farmworkers (35.0% girls and 65.0% boys). Overall, 21.4% of children reported having been told by a medical provider that they had asthma, yet based on a combination of responses to respiratory survey questions, 36.4% or 15% more were identified as having suspected asthma. While 56.4% reported having a regular medical doctor, 38% had not had a medical exam in the past year. Respiratory dysfunction, including suspected, or uncontrolled asthma was prevalent among this group. Latinx children working in agriculture are vulnerable to occupational hazards and exposures and require assurances that they will receive access to high quality healthcare services that include routine respiratory health screenings.

Background: Little research has addressed the safety environment of child farmworkers. This analysis examines the work safety culture experienced by Latinx child farmworkers in North Carolina., Methods: Survey interviews were conducted in 2017 with 202 Latinx children aged 10 to 17 years employed on North Carolina farms. Analysis included measures of the behavioral, situational, and psychological elements of work safety culture., Results: The work culture on North Carolina farms employing Latinx child farmworkers places limited value on safety. Behaviorally, many did not wear appropriate work clothing (e.g., 47.5% wore gloves, 37.1% wore boots). Situationally, few received safety training for tools (40.6%), machinery (24.3%), or pesticides (26.0%); about one-third (33.7%) had worked piece-rate; and many did not have field sanitation services available (e.g., 37.1% had water for washing, 19.8% had soap). Safety attitudes were mixed, and work safety climate was low, with 21.8% stating that their supervisor was only interested in doing the job fast and cheaply. Greater safety training, field sanitation services, and work safety climate were associated with working in western North Carolina, migrant workers, limited English fluency, and working in tomatoes. Wearing appropriate work clothing, not working piece-rate, fewer unsafe work attitudes were associated with working in eastern North Carolina, seasonal worker, speaking English, and working in tobacco., Conclusions: This research makes it apparent that efforts are needed to improve safety culture wherever child farmworkers are employed. Current policy is not providing a safe environment for children working on farms in the United States., Competing Interests: Conflict of Interest Disclosure: The authors report no conflicts of interest.

Increasingly hotter temperatures threaten the environment and pose serious risks to human health. From contending with damaged crops and loss of work due to extreme weather to working in life-threateningly hot and humid temperatures, agricultural farmworkers are on the front lines of this harsh reality., (©2020 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Over the past century, anthropogenic activities have resulted in high levels of greenhouse gases in our environment, creating a warming effect on the Earth. As a result, global temperatures have risen, shifting climatic zones, influencing weather patterns, and intensifying storms. These changes include heavy precipitation, drought, wildfires, hurricanes, heat waves, and coastal flooding. The impacts from this climatic activity continue to contribute negatively to our environment while influencing human health.In this special issue of the North Carolina Medical Journal , authors from universities, governmental agencies, and not-for-profit organizations address how the global impacts of climate change are affecting the health of communities across our beautiful state. This issue offers our readers research and real-life stories that underscore the need for keeping the issue of climate change at the forefront of public health for North Carolina. The information provided in these articles gives policymakers and health care providers a deeper understanding of the public health implications and challenges of climate change while highlighting the health risks to our most susceptible populations.Because there are no direct clinical symptoms or signs, the effects of climate change are difficult to assess at the individual level. However, an abundance of peer-reviewed climate health research studies provides overwhelming scientific evidence that climate change is impacting population health with generalizable results. Mitigation and adaptability strategies are necessary for reducing carbon emissions and building climate-resilient communities. Policymakers and health care providers are in key positions for educating others, helping protect our planet, improving health outcomes, and moving North Carolina toward more sustainable solutions., (©2020 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Children as young as ten are legally hired for farm work. In North Carolina, many of these hired children are Latinx; they often work long hours during hot and humid summer conditions. Heat-related illness occurs along a continuum of severity ranging from heat cramps and rashes to heat exhaustion and heat stroke, which can be fatal. The literature on the negative health effects of occupational heat exposure is growing; however, few studies have examined this exposure and health outcomes among child agricultural workers. To understand Latinx child farmworkers' experiences of working in heat, we conducted in-depth interviews (n = 30). To estimate the prevalence of heat-related illness symptoms and associated factors, we conducted survey interviews (n = 165). Heat-related illness is common among these child farmworkers. While children often understand the dangers of working in heat, work organization often prevents their taking precautions. Formal workplace protections to prevent heat-related illness are limited.

Introduction: Despite the significant decline in overall death rates in the U.S. over the past decade, many asthma deaths could have been avoided. Eastern North Carolina (N.C.) is an economically challenged region with significant health disparities and a high prevalence of asthma. Objective: The primary purpose of this project was to examine trends of asthma deaths across N.C. and identify counties in the state with the highest mortality rates over an 18-year period. Methods: CDC WONDER was used to query and evaluate age-adjusted asthma mortality rates from 1999 to 2016 among residents in N.C., greater than 1 year of age. Asthma death data were derived from death certificates using ICD-10 underlying cause-of-death codes J45 (asthma) and J46 (status asthmaticus). The Join point regression program was used to test statistical significance in age-adjusted rates for the U.S. and N.C. over the entire study period. Results: N.C. experienced a total of 2,066 decedents assigned as the underlying cause of deaths for an overall death rate of 12.5 per 1,000,000 persons. Death rates were highest among females (14.6 deaths per 1,000,000) and black or African Americans (24.7 per 1,000,000). Discussion: Overall asthma mortality rates in N.C. decreased. However, several rural and impoverished counties in eastern N.C. with a large percent of blacks or African-Americans, had the highest asthma death rates in the state. Conclusion: Healthcare providers should remain highly cognizant to provide optimal asthma management, education, and follow-up with asthma patients to help avoid unnecessary asthma related deaths.

Children as young as 10 years old are hired to work on farms in the United States (U.S.). These children are largely Latinx. Using interview data collected from 202 North Carolina Latinx child farmworkers in 2017, this analysis documents the heath characteristics and occupational injuries of Latinx child farmworkers and delineates characteristics associated with their health and occupational injuries. Latinx child farmworkers include girls (37.6%) and boys (62.4%), aged 10 to 17 years, with 17.8% being migrant farmworkers. Three-quarters reported receiving medical and dental care in the past year. Respiratory (15.8%) and vision (20.3%) problems were prevalent. Girls more than boys, and younger more than older children had greater health service utilization. Occupational injuries were common, with 26.2% reporting a traumatic injury, 44.1% a dermatological injury, 42.6% a musculoskeletal injury, and 45.5% heat-related illness in the past year. Age increased the odds of reporting work injuries and heat-related illness, and being a non-migrant reduced the odds of reporting work injuries. These results emphasize the need for greater documentation of child farmworker occupational health and safety. They underscore the need to change occupational safety policy to ensure that children working in agriculture have the same protections as those working in all other U.S. industries.

The geographic position and high level of poverty in the southeastern United States are significant risk factors that contribute to the region's high vulnerability to climate change. The goal of this study was to evaluate beliefs and perceptions of global warming among those living in poverty in the poorest counties in the southeastern United States. Results from this project may be used to support public health efforts to increase climate-related messaging to vulnerable and underserved communities. This was an ecological study that analyzed public opinion poll estimates from previously gathered national level survey data (2016). Responses to 5 questions related to beliefs, attitudes, and perceptions of global warming were evaluated. Counties below the national average poverty level (13.5%) were identified among 11 southeastern US states (Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Michigan, North Carolina, South Carolina, Tennessee, Virginia). Student t tests were used to compare public perceptions of global warming among the poorest urban and rural counties with national-level public opinion estimates. Overall, counties below the national poverty level in the southeastern US were significantly less likely to believe that global warming was happening compared with national-level estimates. The poorest rural counties were less likely to believe that global warming was happening than the poorest urban counties. Health care providers and public health leaders at regional and local levels are in ideal positions to raise awareness and advocate the health implications of climate change to decision makers for the benefit of helping underserved communities mitigate and adequately adapt to climate-related threats.

Background: It has been over a decade since a comprehensive study has been published that has examined sarcoidosis deaths at the national level. The purpose of this study was to analyze sarcoidosis as the underlying cause of death using current national death certificate data. Results from this project can be used to evaluate and compare trends of sarcoidosis reported deaths across the U.S., Methods: Mortality data from 1999 to 2016 were provided by the National Vital Statistics System (NVSS) with sarcoidosis (ICD-D86.X) as the underlying cause of death from all resident death certificates filed in the 50 states and the District of Columbia (DC). Data were analyzed using CDC WONDER, a web-based public health database and analysis tool. Queries were used to generate number of deaths, along with unadjusted and age-adjusted death rates with 95% confidence intervals and standard errors for groups including year, census region, gender, age group, race/ethnicity and state. Joinpoint regression analysis was used to test the significance of trends in race and gender-specific rates for the 1999-2016 study period., Results: From 1999 to 2016, there were a total of 16,665 sarcoidosis reported deaths in the U.S. The overall age-adjusted mortality rate increased from 2.1 (deaths per 1,000,000) in 1999 to 3.1 in 2002, but then remained relatively stable thereafter until the end of the study period. Female deaths increased 32.0% (from 2.5 to 3.3 per 1,000,000), while male deaths increased 73.3% (from 1.5 to 2.6 deaths per 1,000,000). The highest age-adjusted death rates were among black females (17.0 deaths per 1,000,000), and black males (12.4 deaths per 1,000,000). At the regional level, the southern U.S. had the highest overall mean age-adjusted mortality rate (3.7 deaths per 1,000,000), while black females in the Midwest (18.7 per 1,000,000) had the highest race-specific reported death rate., Discussion: The detected increase in the total number of deaths and age-adjusted rates of sarcoidosis deaths in the U.S. is a serious health concern. Factors that contribute to sarcoidosis deaths remain uncertain and more epidemiological research studies are needed to compliment current bench science to explore and examine factors that contribute to this multifactorial, chronic disease., (Copyright © 2018. Published by Elsevier Ltd.)

Background: Although children as young as 10 years can work in agriculture, little research has addressed their occupational health. This paper describes a large, multicomponent study of hired Latinx child farmworkers, and the characteristics of children participating in this study., Methods: Survey interviews were conducted in 2017 with 202 Latinx children aged 10-17 years employed in agriculture across North Carolina (NC)., Results: Most (81.2%) participants were born in the United States, 37.6% were female, and 21.3% were aged 10-13 years. Most (95.1%) were currently enrolled in school. Thirty-six (17.8%) were migrant workers. 34.7% had worked in agriculture for 1 year; 18.3% had worked 4+ years. 33.7% worked piece rate. 57.4% worked in tobacco. Participants in western NC differed in personal and occupational characteristics from those in eastern NC., Conclusions: This study has enrolled a large and diverse child farmworker sample. This overview indicates several important issues for further analysis., (© 2018 Wiley Periodicals, Inc.)

BACKGROUND Recognizing that health outcomes are associated with climate threats is important and requires increased attention by health care providers and policymakers. The primary goal of this report is to provide information related to the public health threats of climate change, while identifying climate-sensitive populations primarily in rural, Eastern North Carolina. METHODS Publicly available data was used to evaluate regional (eg, Eastern, Piedmont, and Western) and county level socio-vulnerability characteristics of population groups in North Carolina, including: percent of persons living in poverty, percent of non-white persons, percent of persons under 18 years living in poverty, percent of elderly people living in poverty, percent of persons with a disability, and number of primary care physicians. One-way ANOVA was used to calculate and compare mean value estimates of population socio-vulnerability variables in Eastern North Carolina with Piedmont and Western regions. RESULTS Across all regional categories, the eastern part of the state had considerably higher averages than the state for percent of persons living in poverty (17.2%), percent of non-white persons (13.3%), percent of persons under 18 years old living in poverty (24.9%), percent of elderly people living in poverty (10.0%), and percent of persons with a disability (13.3%). Overwhelmingly, more counties in Eastern North Carolina had fewer primary care physicians (per 10,000 persons) than the state average (8.6 per 10,000 persons). CONCLUSION Eastern North Carolina has a disproportionally higher percent of population groups that are vulnerable to the threats of climate change. The need for health care providers to understand and communicate the challenges faced by rural, vulnerable population groups is of great public health importance. Communicating these health risks to policy makers is of equal importance., (©2018 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

BACKGROUND The purpose of this study was to compare asthma-related emergency department (ED) visit rates across North Carolina. Results from this study can inform health planning while helping public health and health care professionals in identifying geographical areas and targeting age groups to reduce the asthma burden in North Carolina. METHODS This was a retrospective data analysis between 2010 and 2014 among North Carolina patients presenting to an ED with a first or second listed diagnosis code related to asthma (ICD-9-CM, 493.xx). Data was obtained from the North Carolina Disease Event Tracking and Epidemiology Collection Tool. Annual, age-adjusted rates were standardized to the 2000 US standard population using the direct method. Repeated measures ANOVA was conducted to compare differences between mean values of asthma-related ED visit rates in regions, urbanicity, and age groups across years. RESULTS Asthma ED rates were consistently higher in the east (85.1 per 10,000) compared with other regions. While most age group ED rates fluctuated over the study period, univariate test results indicated statistical increases in ED asthma visits among the groups aged 5 to 9 years ( P < .01), and 65 and over ( P < .03). CONCLUSION Public health officials should recognize the disproportionate burden of asthma-related ED visits, particularly among rural and impoverished counties in the eastern portion of North Carolina when prioritizing health concerns across North Carolina., (©2018 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Competing Interests: Declaration of conflicting interests:The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Editorial co-author Dr. Greg Kearney authored articles on an intervention study among rural and underserved children with asthma (Kearney et al, 2014) and Upstream Asthma (Kearney et al, 2017).

: Workers are uniquely susceptible to the health hazards imposed by environmental changes. Occupational and environmental medicine (OEM) providers are at the forefront of emerging health issues pertaining to working populations including climate change, and must be prepared to recognize, respond to, and mitigate climate change-related health effects in workers. This guidance document from the American College of Occupational and Environmental Medicine focuses on North American workers health effects that may occur as a result of climate change and describes the responsibilities of the OEM provider in responding to these health challenges.

BACKGROUND Inmates face challenges upon release from prison, including increased risk of death. We examine mortality among former inmates in North Carolina, including both violent and nonviolent deaths. METHODS A retrospective cohort study among former North Carolina inmates released between 2008 and 2010 were linked with North Carolina mortality data to determine cause of death. Inmates were followed through December 31, 2012. Mortality rates among former inmates were compared with deaths among North Carolina residents using standardized mortality ratios (SMRs). RESULTS Among former inmates (N = 41,495), there were 926 deaths during the study period. Compared to the North Carolina general population, SMRs were higher for all-cause mortality for total deaths (SMR = 2.10, 95% CI: 1.97-2.24), heart disease (SMR = 4.45, 95% CI: 3.64-5.34), cancer (SMR = 3.92, 95% CI: 3.34-4.62), suicide (SMR = 14.46, 95% CI: 10.28-19.76), and homicide (SMR = 7.98, 95% CI: 6.34-10.03). DISCUSSION The death rate among former North Carolina inmates is significantly higher than that of other North Carolina residents. Although more research is needed, identifying areas for interventions is essential for reducing the risk of death among this population., (©2017 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Background: Each year, the average number of nonfatal occupational injuries among landscaping and groundskeeping workers are consistently above the total number of injuries for all other occupational injuries among worker in the U.S. From 2004 to 2007, fatalities among groundskeepers averaged 13.3 per 100,000 workers compared to an overall rate of 4.0 fatalities per 100,000 for all U.S. workers with the majority reported as either Hispanic or Latino., Objective: The aims of this project were to describe the use of personal protective equipment and work safety climate among a sample of landscaping and groundskeeping workers employed by public universities in North Carolina (N = 67)., Methods: Data from a cross-sectional study was collected among workers using group- administered surveys. Statistical associations with work safety climate were tested between personal, work and safety behavior characteristics with work safety climate scores using one-way ANOVA., Results: Nearly half of workers (49.3%) reported experiencing one or more work-related injuries or illnesses within the past 12 months. While work safety practices were perceived as being very important to management, only 56.7% reported having regular safety meetings. In bivariate analysis, work safety climate scores were significantly lower among those reporting race "other than white" (P = 0.01)., Conclusions: This is the first study of its kind to evaluate work safety climate among landscaping and groundskeeping workers. Although self-reported safety practices were moderate, minority workers described their work safety climate as being poor. As a pilot study, these results suggest that employers of landscaping and groundskeeping workers could do more to improve safety climate within the organization with an emphasis on safety training for minority and underrepresented workers.

Background: Fractional concentration of exhaled nitric oxide (FeNO) is recommended by the American Thoracic Society (ATS) as a noninvasive biomarker of airway inflammation. In addition to inflammation, many factors may be associated with FeNO, particularly tobacco exposure; however, only age has been included as an influential factor for children below 12 years. Numerous studies have demonstrated negative associations between tobacco exposure and FeNO levels with self-reported data, but few with an objective assessment of smoking., Methods: Data from the National Health and Nutrition Examination Survey (NHANES) 2007-2012 were analyzed to examine the association between FeNO and active/passive tobacco. Exposure was assessed by both self-report and serum cotinine levels among 11,160 subjects aged 6-79 years old with asthma, or without any respiratory disease., Results: Study results indicated 28.8% lower FeNO, 95% CI [25.2%, 32.3%] and 38.1% lower FeNO, 95% CI: [28.1, 46.2] was observed among healthy and asthmatic participants with serum cotinine in the highest quartile compared to those in the lowest quartile, respectively. Self-reported smoking status and recent tobacco use were also associated with decreased FeNO. Self-reported passive smoking was significantly associated with a 1.0% decrease in FeNO 95% CI [0.0, 2.0] among asthmatic subjects but not among healthy subjects., Conclusions: Active smoking, whether measured by self-report or serum cotinine, was associated with decreased FeNO levels. In addition to age, increased attention should be given to tobacco exposure when using FeNO as a biomarker in clinical practice. Additional research is needed to establish reference value of FeNO considering the impact of tobacco exposure.

Groundskeepers may have increased risk to noise-induced hearing loss due to the performance of excessively noisy tasks. This study assessed the exposure of groundskeepers to noise in multiple universities and determined the association between noise exposure and variables (ie, university, month, tool used). Personal noise exposures were monitored during the work shift using noise dosimetry. A sound level meter was used to measure the maximum sound pressure levels from groundskeeping equipment. The mean Occupational Safety and Health Administration (OSHA) and National Institute for Occupational Safety and Health (NIOSH) time-weighted average (TWA) noise exposures were 83.0 ± 9.6 and 88.0 ± 6.7 dBA, respectively. About 52% of the OSHA TWAs and 77% of the NIOSH TWAs exceeded 85 dBA. Riding mower use was associated with high TWA noise exposures and with having OSHA TWAs exceeding 85 and 90 dBA. The maximum sound pressure levels of equipment and tools measured ranged from 76 to 109 dBA, 82% of which were >85 dBA. These findings support that groundskeepers have excessive noise exposures, which may be effectively reduced through careful scheduling of the use of noisy equipment/tools.

The aim of this pilot study was to evaluate respiratory behavior and respiratory indices of poultry workers on family-owned, poultry farms with 10 or less employees in North Carolina. A field study was conducted to collect data on participants (N = 24) using spirometry, fractional exhaled nitric oxide (Feno), and an interviewer-administered questionnaire. The majority of workers (76%) ranked respiratory protection as being important, yet 48% reported never or rarely wearing respiratory protection when working in dusty conditions. A large percent of workers reported eye (55%) and nasal (50%) irritation and dry cough (50%). On average, pulmonary lung function and Feno tests were normal among nonsmokers. In bivariate analysis, significant associations were identified between working 7 days on the farm (P = .01), with eye irritation, and working 5 or fewer years in poultry farming (P = .01). Poultry workers on family-owned farms spend a considerable amount of work time in poultry houses and report acute respiratory-related health symptoms. Administrative controls among small, family-owned poultry farms are necessary to improve and promote safety and health to its employees.

Approximately 870,000 U.S. workers are employed as landscaping and groundskeeping workers who perform various tasks and use a variety of tools that expose them to high noise levels, increasing their risk to noise-induced hearing loss (NIHL). Several studies on noise exposure and NIHL in other job sectors have been published, but those on groundskeepers are very limited. This study aims to characterize the noise exposure of groundskeepers. Participants were monitored over their entire work shift for personal noise exposure by wearing noise dosimeters at shoulder level, 4 in from the ear. Using two different dosimeter settings (OSHA and NIOSH), the time-weighted averages (TWAs) and 1-min averages of noise exposure levels in decibels (dBA) were obtained. The participants were also asked to fill out an activity card daily to document their tasks, tools used, location and noise perception. Sound pressure levels (SPLs) produced by various groundskeeping equipment and tools were measured at full throttle near the ear of the operator using a sound level meter. These measurements were used to assess worker noise exposure profiles, particularly the contributing source of noise. The overall mean OSHA and NIOSH TWA noise exposures were 82.2±9.2 (range of 50.9-100 dBA) and 87.8±6.6 dBA (range of 67.2-102.9 dBA), respectively. Approximately 46% of the OSHA TWAs exceeded the OSHA action limit of 85 dBA. About 76% of the NIOSH TWAs exceeded 85 dBA, and 42% exceeded 90 dBA. The SPLs of equipment and tools measured ranged from 75- 106 dBA, most of which were at above 85 dBA and within the 90-100 dBA range. Hand-held power tools and ride-on equipment without enclosed cab may have contributed significantly to worker noise exposure. This study demonstrates that groundskeepers may be routinely exposed to noise levels above the OSHA and NIOSH exposure limits, and that the implementation of effective hearing conservation programs is necessary to reduce their risk to NIHL.

Agricultural work is a physically demanding occupation. The purpose of this project was to describe the prevalence of work-related musculoskeletal disorders (WMSDs) and self-reported pain among Latino farmworkers who work extensively hand harvesting sweet potatoes. Data were obtained from a cross-sectional survey of farmworkers (N = 120) in eastern North Carolina. Univariate and bivariate analyses were used to describe personal, work characteristics, and self-reported pain associated with musculoskeletal injuries. Overall, 79% of farmworkers reported any type of pain or discomfort. The highest reported areas of pain were in the back (66%) and shoulder areas (31%). Younger participants experienced more shoulder pain (P = .04) than older workers, and working more than 5 years as a farmworker was significantly associated with back pain (P = .01). Interventions aimed at administrative and engineering controls for reducing risk factors that contribute to WMSDs are warranted.

In hot weather, thermal heat generated by the body, combined with environmental heat from the sun, can lead outdoor workers to experience heat-related stress, severe illness, or even death. The aims of this study were to estimate the prevalence of heat-related symptoms and potential risk factors associated with sun safety-related behavior among Latino farmworkers. Data from interviewer-administered questionnaires were collected from a cross-sectional survey among farmworkers (N = 158) from August to September 2013. Data analysis assessed associations between work activities, sun safety behavior, and the prevalence of heat-related illness (HRI) symptoms among workers. Nearly two thirds (72%) of farmworkers experienced at least one HRI symptom and lacked proper cooling methods when working outdoors. Most workers reported wearing long-sleeved shirts (85%), long pants (98%), and baseball caps (93%). The prevalence of having one HRI symptom was 72% and 27% among workers having three or more HRI symptoms. The majority of farmworkers experience symptoms of HRI and are not provided with proper shade protection when working outdoors. Increased emphasis on administrative controls, particularly educating field supervisors and workers on how to avoid and recognize HRI, should be a priority.

The purpose of this study was to assess the attitude toward noise, perceived hearing symptoms, noisy activities that were participated in, and factors associated with hearing protection use among college students. A 44-item online survey was completed by 2,151 college students (aged 17 years and above) to assess the attitudes toward noise, perceived hearing symptoms related to noise exposure, and use of hearing protection around noisy activities. Among the participants, 39.6% experienced at least one hearing symptom, with ear pain as the most frequently reported (22.5%). About 80% of the participants were involved in at least one noise activity, out of which 41% reported the use of hearing protection. A large majority of those with ear pain, hearing loss, permanent tinnitus, and noise sensitivity was involved in attending a sporting event, which was the most reported noisy activity. The highest reported hearing protection use was in the use of firearms, and the lowest in discos/ dances. The reported use of hearing protection is associated with having at least one hearing symptom but the relationship is stronger with tinnitus, hearing loss, and ear pain (χ² = 30.5-43.5, P< 0.01) as compared to noise sensitivity (χ² = 3.8, P= 0.03); it is also associated with anti-noise attitudes, particularly in youth social events. Universities and colleges have important roles in protecting young adults' hearing by integrating hearing conservation topic in the college curriculum, promoting hearing health by student health services, involving student groups in noise-induced hearing loss (NIHL) awareness and prevention, and establishing noise level limitations for all on-campus events.

Objectives: The aims of this project were to describe the work safety climate and the association between occupational safety behaviors and injuries among hired youth farmworkers in North Carolina (n = 87)., Methods: We conducted personal interviews among a cross-sectional sample of youth farmworkers aged 10 to 17 years., Results: The majority of youths reported that work safety practices were very important to management, yet 38% stated that supervisors were only interested in "doing the job quickly and cheaply." Few youths reported appropriate work safety behavior, and 14% experienced an injury within the past 12 months. In bivariate analysis, perceptions of work safety climate were significantly associated with pesticide exposure risk factors for rewearing wet shoes (P = .01), wet clothes (P = .01), and shorts (P = .03)., Conclusions: Youth farmworkers perceived their work safety climate as being poor. Although additional research is needed to support these findings, these results strengthen the need to increase employer awareness to improve the safety climate for protecting youth farmworkers from harmful exposures and injuries.

Background: The creation of the Centers for Disease Control and Prevention Environmental Public Health Tracking Program spawned an invigorating and challenging approach toward implementing the nation's first population-based, environmental disease tracking surveillance system. More than 10 years have passed since its creation and an abundance of peer-reviewed articles have been published spanning a broad variety of public health topics related primarily to the goal of reducing diseases of environmental origin., Objective: To evaluate peer-reviewed literature related to Environmental Public Health Tracking during 2002-2012, recognize major milestones and challenges, and offer recommendations., Design: A narrative overview was conducted using titles and abstracts of peer-reviewed articles, key word searches, and science-based search engine databases., Main Outcomes: Eighty published articles related to "health tracking" were identified and categorized according to 4 crossed-central themes. The Science and Research theme accounted for the majority of published articles, followed by Policy and Practice, Collaborations Among Health and Environmental Programs, and Network Development., Conclusions: Overall, progress was reported in the areas of data linkage, data sharing, surveillance methods, and network development. Ongoing challenges included formulating better ways to establish the connections between health and the environment, such as using biomonitoring, public water systems, and private well water data. Recommendations for future efforts include use of data to inform policy and practice and use of electronic health records data for environmental health surveillance.

Objectives: We analyzed aspects of the behavioral, situational, and psychological elements of work safety culture of hired youth farmworkers in North Carolina., Methods: Data were from interviewer-administered questionnaires completed with 87 male and female hired farmworkers aged 10 to 17 years in North Carolina in 2013. We computed means, SDs, and Cronbach α values for the perceived work safety climate and safety perception summary scores., Results: Hired youth farmworkers in North Carolina described a negative work safety culture. Most engaged in unsafe general and unsafe work behaviors, few received training, and many were sexually harassed at work. They had mixed safety attitudes and knew that their employment was precarious. They reported a poor perceived work safety climate characterized by the perception that their supervisors "are only interested in doing the job fast and cheaply." However, we could not detect statistically significant associations between work safety culture and injuries among these farmworkers., Conclusions: Increased scrutiny of agriculture as a suitable industry for workers as young as 10 years and additional regulations to protect hired youth farmworkers, if not to remove them from this environment, are warranted. Additional research is needed.

Purpose: Polycyclic aromatic hydrocarbons (PAHs) are ubiquitous environmental toxic compounds formed from incomplete combustion of carbon-containing materials, cigarette smoking, and food cooking. The genotoxic effects of PAHs have been widely studied. However, their nongenotoxic effects such as their impacts on glucose and metabolic homeostasis have not been well examined., Methods: We used the National Health and Nutritional Examination Survey (NHANES) 2001-2008 to investigate the associations between eight monohydroxy urinary metabolites of four PAHs and glucose homeostasis as well as metabolic syndrome in 1,878 nondiabetic participants aged 18 years or older., Results: In linear regression models, increased level of 2-PHEN was significantly associated with increased insulin resistance (β coefficient 0.05 ± 0.02), and increased concentrations of 3-FLUO (β coefficient -0.02 ± 0.01) were significantly associated with decreased β-cell function (all p<0.05) after controlling for selected covariates. In addition, increased concentrations of 2-FLUO (OR=1.25, 95% CI: 1.04-1.51), 1-PHEN (OR=1.36, 95% CI: 1.09-1.70), and 2-PHEN (OR: 1.49, 95% CI: 1.22-1.83) were significantly associated with a higher prevalence of the metabolic syndrome after adjusting for covariates. Consistent results were observed in the subgroup analysis among nonsmokers., Conclusions: Our findings suggest that environmental exposure to PAHs independent of cigarette smoking is associated with insulin resistance, β-cell dysfunction, and increased prevalence of metabolic syndrome., (Copyright © 2014 Elsevier B.V. All rights reserved.)

The objective of the study described here was to determine basic plans and collaboration with first responder stakeholders and to identify perceived roles and responsibilities in preparing for and responding to a chemical disaster. A survey was developed and provided to environmental health personnel at county health departments (CHDs) in Florida. Most of the counties had good collaborative relationships with first responder stakeholders. A little more than half of the respondents had access to a resource manual with contact information and had developed and maintained a chemical plan. Rural counties were less likely to know "what to do" or their responsibility in a chemical disaster; however, both rural and nonrural counties were equally likely not to have a written plan. Public health agencies at the local CHD must be the communicators of public health messages in coordination with the incident commander and the state communications office in a chemical disaster, so it is important to strengthen collaboration and cooperation with chemical response stakeholders.

Farming is among the most dangerous industries for fatal and nonfatal injuries. A comprehensive agricultural injury surveillance system is absent in North Carolina (NC), and data sets traditionally used to provide estimates of nonfatal farm injuries surveillance in the United States are relatively incomplete. In the absence of a comprehensive farm injury surveillance system, individual local administrative data sources can provide a useful profile of the epidemiology of injuries in a population. The objective of this study was to use emergency department data to help describe the burden of farm-related injuries in NC and explore its usefulness in conducting work-related injury surveillance. Emergency department data from the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) was utilized to identify farm injury cases. The study sample included all farm injury cases for the period of 2008-2012 that contained International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) E code 919.0 (agricultural machinery) or 849.1 (place of occurrence = farm; this E code excludes farm house and home premises of farm). Results indicated that an average of 459 cases of farm injury occurred annually from 2008 to 2012, with no significant change between years. Among the patients, 79.7% were male, 74.7% were between 18 and 64 years old, and 28.1% had no form of insurance coverage. Injuries were more heavily concentrated in the Piedmont and Coastal Plains regions (41.3% and 42.2%, respectively). Of farm-coded incidents, 73.2% were given injury- or poisoning-related primary diagnosis codes, and of these, the most frequent specific codes were related to open wounds of upper limbs (16.2%), contusions (12.0%), and sprains and strains (9.3%). Some significant relationships between diagnoses and sex, region, and age are also identified. Injuries occurring on a farm have been well documented and constitute a significant public health problem. Exploring emergency department data provides an opportunity to better characterize nonfatal farm-related injuries in NC for prevention purposes. The data provided by this study may serve to direct prevention programs, whereas the methods used offer a potential farm-related injury surveillance tool.

Agriculture consistently ranks among the top hazardous occupations, accounting for a significant number of injuries and fatalities in the workplace. Eastern North Carolina has a significant number of small, independent, family-run, owned, and operated farms. However, little is known about perception, behavior, training, accessibility, or purchasing personal protective equipment (PPE) for safety among farmers in the region. In this study, telephone interviews were conducted among participating farmers between March and June 2012 (N = 129). Univariate and bivariate analyses were conducted to examine associations between PPE behavior and workplace hazards, health-related concerns, and wearing and purchasing PPE. Findings indicated that personal behavior of wearing hearing protection devices (HPDs) and protection from the sun among farmers was low. However, a relatively high percentage of farmers reported wearing PPE when working with agricultural chemicals. Most farmers received training from agricultural extension offices. The findings indicate that, in general, farmers are well aware of the risks associated with occupational hazards and recognize concern for health and safety protection in the workplace. Transitioning these concerns into preventative action remains a challenge and priority for the agricultural health professional.

Objective: Farmworkers are at an increased risk of skin cancer from exposure to excessive amounts of ultraviolet radiation from the sun. The primary objective of this study was to evaluate sun protection behaviors., Methods: A cross-sectional study of Latino farmworkers in eastern North Carolina was conducted using personal interviews followed by a full-body examination for skin cancers (N = 157)., Results: Participants were predominately, young, males from Mexico who spent 9 or more hours each work day in the sun. Most reported wearing long sleeved shirts (85.7%) and long pants (98.0%). Few workers rarely used sunscreen (90.8%) or wore sunglasses (87.4%). Skin cancers were not identified among workers., Conclusions: In general, farmworkers lack sufficient information and knowledge about the risks of skin cancer from the sun. Interventions for reducing excessive ultraviolet radiation exposures are warranted.

Background: Agriculture is a hazardous, stressful occupation that can adversely affect farmers' health. Identifying stressors among farmers may help health professionals improve health outcomes by developing targeted intervention strategies and services., Methods: Over a 4-month period, we conducted a cross-sectional study of 128 farmers in an economically disadvantaged, 29-county region of Eastern North Carolina. We used a modified version of the Farm Ranch Stress Inventory to measure farmers' self-reported reactions to potential stressors., Results: The majority of farmers surveyed were aged 40-59 years, had farmed for more than 20 years, and worked more than 40 hours per week on the farm. Large proportions of respondents identified the following factors as 'very stressful': concern about the weather (60.2%), concern over the future of the farm (29.7%), outsiders not understanding the nature of farming (25.2%), problems with machinery (23.4%), market prices for crops/livestock (45.3%), taxes (38.3%), health care costs (32.5%), and not having enough time to spend with family in recreation (13.3%). Experiencing 8 or more factors as "very stressful" was found to be positively associated with working more than 40 hours per week on the farm (P = .008) and with being a farm manager or a farm worker who does not operate equipment (P = .001)., Conclusions: Information about perceived stressors among farmers may help health professionals develop targeted interventions for reducing stress. More research is needed to better evaluate health outcomes, to reduce farm-related injuries, and to improve psychosocial well-being.