SummaryThe Rural Health Initiative (a nonprofit agency) sends registered nurses with farming backgrounds to farms in three Wisconsin counties to provide free preventive health and occupational safety screenings to farmers and their adult family members and employees. The nurses take a medical history, perform routine screenings, and provide health education and counseling on relevant issues. They also tour the farm to identify safety issues, providing farmers with a list of potential hazards that should be addressed. They typically return several weeks later to review test results and, if necessary, make referrals for appropriate followup care. The program has enhanced access to routine medical care and safety screenings, improved eating habits and high-density lipoprotein levels, and generated high attendance at followup appointments and high levels of satisfaction. Many participating farmers report making safety improvements in response to issues identified by the nurses.Moderate: The evidence consists of trends in eating habits and HDL levels among participants, with comparisons between the initial and subsequent visits. Other evidence includes post-implementation survey data on the percentage of participants following up on referrals, participant satisfaction with various aspects of the program, and participant follow-through on addressing issues identified in the occupational safety assessment.
Developing OrganizationsRural Health Initiative
Date First Implemented2003
Vulnerable Populations > Rural populations
Problem AddressedFarmers often do not get preventive care because they lack adequate health insurance and/or face barriers to seeing a doctor on a regular basis. As a result, treatable health problems often go undiagnosed and/or untreated, which increases the long-term risk of serious illness and death.
- Inadequate insurance: Many farmers either lack insurance or have high-deductible plans that do not cover checkups and preventive care. In Wisconsin, more than 18 percent of dairy farm families have no health insurance, and another 41 percent have high-deductible plans that typically require policyholders to pay the first $5,000 to $10,000 of medical bills each year.1 Low-income farmers with no or inadequate insurance seldom take advantage of government-sponsored sources of care, as they tend to distrust government and believe in minimal government intervention.2
- Other barriers to regular office visits: Several work-related and cultural issues create barriers to farmers attending regular doctor visits. Farmers typically work long hours and do not want to sacrifice a half-day of work to see a doctor. They also value self-reliance and are used to having service providers (e.g., veterinarians, suppliers, mechanics) come to the farm (rather than traveling to receive services).2
- Unaddressed health issues: Farmers who fail to get regular medical care often develop treatable medical conditions such as hypertension, diabetes, obesity, hearing and vision loss, arthritis, depression, and skin disorders. They also frequently suffer accidents (since farming is a high-risk occupation) that can cause severe bruising and/or broken bones. In the absence of regular care, these problems cannot be diagnosed or treated, which over time increases the risk of serious illness and death.3
Description of the Innovative ActivityThe Rural Health Initiative sends registered nurses with farming backgrounds to farms in three Wisconsin counties to provide free preventive health and occupational safety screenings to farmers and their adult family members and employees. The nurses take a medical history, perform routine screenings, and provide health education and counseling on relevant issues. They also tour the farm to identify any safety issues, providing farmers with a list of potential hazards to be addressed. They typically return several weeks later to review test results and, if necessary, make referrals for appropriate followup care. Key components of the program are described below:
- Generating appointments: Nurses conduct screenings only after being invited to do so by the farmers. To generate awareness and interest, nurses periodically accompany other people who routinely visit farms, such as University of Wisconsin extension agents, veterinarians, suppliers, and milk haulers. While visiting, they discuss the benefits of the screenings. They also speak at gatherings likely to include farmers, such as public events (where they also might perform the screenings) and meetings of alumni groups, cooperative groups, equipment dealers, and the Future Farmers of America. Many first-time appointments result from people hearing about the screenings from existing participants.
- On-the-farm screenings: Screenings take place on the farm and cover both health and safety issues, as outlined below:
- Health screenings, history, and education: The health screening typically occurs in participants' kitchens, where they tend to be relaxed and comfortable. The nurse checks the individual's height, weight, blood pressure, vision, and hearing. The nurse also draws blood to measure blood glucose and cholesterol levels, and evaluates the individual's mental health using a screening test adapted from material from the National Institute of Mental Health. During the first appointment, the nurse takes the patient's medical history and asks about current health problems. If the person has had previous visits, the nurse asks about changes since the last visit and about progress and challenges in addressing health issues. Nurses also give advice on general health issues (such as healthy eating, exercise, smoking cessation, and prevention of cancer and heart disease) and answer any questions the participant may have. If necessary, nurses also help with insurance issues, such as referring people without coverage to insurers and helping those with insurance understand their coverage and bills.
- Safety screening: The nurse usually tours the farm, using a safety checklist to point out potential hazards. During the tour, the nurse discusses relevant farm-related health issues, such as using protective equipment (e.g., ear muffs), storing chemicals appropriately, applying sunscreen, strategies for avoiding work-related knee and back injuries, and appropriate availability and administration of first aid. Farmers receive a corrective action sheet that details areas on the farm that do not meet safety standards. Those that attain a total safety score of 85 percent or higher receive a certificate designated their farm as a "certified safe farm."
- Referrals and other followup care: In rare cases, such as if participants have dangerously high blood pressure or appear to be suicidal, the nurse helps arrange for immediate care (e.g., by having the participant immediately call a doctor or instructing a family member to take the person to the emergency department). More commonly, the nurse returns several weeks later to review test results, discuss recommended health strategies, and, if necessary, advise participants to see a primary care doctor or specialist. Nurses also make occasional followup phone calls between visits to review progress toward established goals. During followup encounters, nurses encourage participants to call if they have questions and to schedule their next annual screening visit.
References/Related ArticlesSchiller LF, Donham K, Anderson T, et al. Incorporating occupational health interventions in a community-based participatory preventive health program for farm families: a qualitative study. J Agromedicine. 2010 Apr;15(2):117-26. [PubMed]
Contact the InnovatorRhonda Strebel
Rural Health Initiative Inc.
100 County Road B
Shawano, WI 54166
Innovator DisclosuresRhonda Strebel reported having no financial interests or business/professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section.
ResultsThe program has enhanced access to routine medical care and safety screenings, improved eating habits and high-density lipoprotein (HDL) levels, and generated high attendance at followup appointments and high levels of satisfaction. Many participating farmers report making safety improvements in response to issues identified by the nurses.
Moderate: The evidence consists of trends in eating habits and HDL levels among participants, with comparisons between the initial and subsequent visits. Other evidence includes post-implementation survey data on the percentage of participants following up on referrals, participant satisfaction with various aspects of the program, and participant follow-through on addressing issues identified in the occupational safety assessment.
- Enhanced access: In 2011, the nurse in Shawano County performed 150 health and safety screenings. It is unlikely that participating farmers would have had access to these services in the absence of this program. (Data on visits in the other two counties are not yet available, since these counties joined the program in 2012.)
- Better eating habits: An assessment of 160 individuals who received visits in Shawano County between 2004 and 2007 found statistically significant improvements in eating habits, including reducing intake of fried foods and high-fat meat and dairy products and increasing consumption of foods high in calcium.
- Higher HDL cholesterol: The same assessment found that participants' average HDL cholesterol levels (i.e., "good" cholesterol) rose by a significant amount, from 44.6 at the initial screening to 50.8 at the next one.
- High follow-through on referrals: Among the approximately 40 percent of participants referred to additional resources, 94.6 percent reported following through with the referrals, which were mostly to providers to address an identified health problem or to receive preventive health services.
- High satisfaction: All participants reported high levels of satisfaction with the program, including the health and safety screenings, telephone consultations, and referrals to community resources. In addition, the vast majority of farmers rated the visiting nurse as knowledgeable or very knowledgeable (88.7 percent), attentive or very attentive (92.0 percent), trustworthy or very trustworthy (87.6 percent), professional or very professional (90.9 percent), and sensitive or very sensitive to their needs (90.8 percent).
- Anecdotal reports of safety improvements: Many farmers reported making improvements in direct response to issues identified in the occupational safety screenings. For example, some reported being more likely to wear personal protective equipment and to use sunscreen and sunglasses, and others reported reducing clutter in tractor cabs, gating manure pits, putting chains on tires, and making sure that first aid kits are readily available.
Context of the InnovationThe Rural Health Initiative is a nonprofit organization created in 2003 by ThedaCare (a community health system consisting of five hospitals and numerous clinics and related services) and other business, health care, and agricultural leaders in Shawano County, WI. Funded through local health care organizations, agribusiness, and private donations, the organization serves farmers, retired farmers, and their family members, with the goal of improving health-related behaviors, occupational safety, and access to health care, preventive services, and community resources.
The impetus for this program came from research conducted by the Community Health Action Team, a volunteer committee affiliated with the Rural Health Initiative comprised of 30 community members with diverse backgrounds (e.g., business, academia, farming, health care). After visiting a large farm and seeing how many farmers either lacked insurance or did not have adequate coverage, the team began exploring ways to improve access to health care services for this at-risk population.
Planning and Development ProcessKey steps included the following:
- Forming workgroup: In 2003, several members of the Community Health Action Team invited about 25 community leaders with expertise in farming and/or an interest in health issues to join a work group charged with developing a program to help uninsured and underinsured farmers. The work group met on a monthly basis.
- Determining program focus: During the group's early meetings, members explored what could be done to reduce the cost of health insurance for farmers. However, they soon realized the many challenges and complexities of doing so, and decided they could not tackle this problem on their own. They shifted their focus to enhancing access to health care services for this population. Recognizing that farmers are accustomed to having service providers come to them, they came up with the idea of having nurses visit the farms.
- Funding and launching pilot program: By mid-2003, organizers agreed on the "home-visit" model and began finalizing program details. Rural Health Initiative initially structured the program as a 3-year pilot with a budget of $120,000 (half from ThedaCare and half from community sources). This funding enabled the January 2004 hiring of a nurse raised on a farm to serve as program coordinator. The nurse began making visits to farm families in February.
- Adding safety component: The program initially focused only on health screenings. In 2006, the coordinator completed a 2-day workshop at the University of Iowa's Center for Agricultural Safety and Health, after which Rural Health Initiative leaders decided to add the farm safety component.
- Securing funds to continue program: Following the success of the 3-year pilot program, Rural Health Initiative secured funding from a range of sources (including a $75,000 Federal grant) to continue the program.
- Forming board and advisory groups: In January 2007, Rural Health Initiative created a board of directors to oversee the program. The board is made up of community members and representatives from various State and regional organizations. Additional volunteers who served on the Community Health Action Team and other work groups now support the board by participating in three formal advisory groups to the program, each focused on a different issue: coaching nurses on clinical health protocols and procedures, marketing the program to farmers, and fundraising.
- Expanding to two other counties: In February 2012, the program expanded to two neighboring counties (Outagamie and Waupaca) in response to requests from local officials. The coordinator hired and trained two additional nurses to cover these counties, along with a new nurse to perform visits in Shawano County. The original coordinator became the executive director of Rural Health Initiative, spending her time on administrative issues, such as supervision, hiring, and fundraising.
Resources Used and Skills Needed
- Staffing: Program staff include an executive director, who devotes all of her work time to the program, and three part-time nurses, who work 10 to 15 hours per week on the program.
- Costs: The annual budget to provide program services in the three counties totals $183,000. Major costs include staff salaries and benefits, medical testing equipment and supplies, and travel-related expenses (e.g., reimbursement for mileage to the nurses).
Major funding sources include ThedaCare, the Wisconsin Office of Rural Health, local agribusinesses, and community foundations. The program receives additional financial support from local hospitals and private donors, and raises money through fundraising events.
Getting Started with This Innovation
- Hire nurses with farming backgrounds: Nurses with an agricultural background (e.g., those who grew up or have worked on farms) are much more likely to quickly develop a rapport with farmers during home visits.
- Choose name carefully: Many farmers have negative perceptions of government programs, so pick a name that does not lead them to believe the program is affiliated with the county or state. Early on, Rural Health Initiative changed its name from the Shawano County Rural Health County Initiative so as to avoid this misperception.
- Make program available to all: The program's popularity stems in part from the fact that farmers need not qualify based on income, net worth, or insurance status. As a result, they perceive the program as a service for all farmers, not a handout for the poor.
Sustaining This Innovation
- Focus on fundraising: Program leaders should strive to secure multiple sources of funding, since any single source could be reduced or eliminated. Potential sources include local, state, and Federal grants, local businesses, and annual fundraisers.
- Partner with academia to evaluate program impact: Cultivating relationships with local colleges and universities can set the stage for researchers to conduct studies documenting the program's impact on health and safety. Sharing such data can be critical to maintaining community support and sustaining fundraising efforts.
1 Donham KJ, Thelen, A. Agricultural medicine: Occupational and environmental health for the health professions. Ames: Blackwell Publishing; 2006.
Kelsey TW. The agrarian myth and policy responses to farm safety. Am J Public Health. 1994 Jul;84(7):1171-7. [PubMed]
3 Williams RT. The ongoing farm crisis: Health, mental health and safety issues in Wisconsin. Rural Mental Health. 2001;26(4):15-7.
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Service Delivery Innovation Profile
Quality Improvement Goals and Mechanisms:
Original publication: November 07, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: November 20, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.