Farm Out Health Project A Participatory Health Needs Assessment of the Local Agricultural Community Linda Syson-Nibbs Public Health Nurse Directorate of Public Health Newholme Hospital Baslow Road Bakewell Derbyshire DE45 1AD Direct Dial: (01629) 817933 Fax: (01629) 817960 [email protected] June 2001 Acknowledgements This health needs assessment has only been possible as result of the significant contribution, support and generosity of spirit of the local farming community. Sincere thanks are also due to Mary Adlen for her expert and enthusiastic secretarial support 2 Farm Out Health Project Participatory health Needs Assessment of the Agricultural Community Executive Summary 1 Background 1.1 The Farm Out Health project is a 3 year initiative set up by High Peak and Dales Primary Care Trust and jointly funded by East Midlands Development Agency in response to the economic decline in farming over the last decade and the deleterious effect this might have on the health of the agricultural community living within the West Derbyshire Rural Development. A key task was to conduct a health needs assessment of the agricultural community from which public health solutions could be identified to meet need. 1.2 The agricultural community is defined as those individuals and families involved in farming or farming related occupations through direct employment or family ties. 2 The Conduct of the Health Needs Assessment 2.1 A participatory health needs assessment was conducted using a range of qualitative and quantitative research methods. This included focus group interviews with community groups who represented the different interests and concerns of the agricultural community and a comparative health survey of agricultural families (n=248) and non- farming (n=248) local families registered with Tideswell surgery in the heart of the Farm Out patch. 2.2 The findings have been presented to the agricultural community and the wider health and social care community at a Health and Agriculture Conference held in Bakewell on July 9 th 2002. Workshops were conducted to validate the findings of the needs assessment and to generate public health solutions. 3 Key Socio Economic Findings 3.1 The area is characterised by small, family run, dairy, beef and sheep hill farms. The high altitude, lower temperatures and shortened growing season mean local farmers have to work hard to maximise the nutritional potential of the land. 3.2 Across the country farming incomes are on average some 25% of their original level 10 years ago. The reasons are complex but include the strength of the pound and weakness of the Euro in which many subsidies are calculated. The BSE crisis, the long-term decline in beef and lamb consumption and the continuing rise in the cost of farm inputs such as tractor fuel, animal feed and fertilizers. 3.3 Although there were no confirmed cases of Foot and Mouth disease in the area the 2001 national outbreak had and continues to have a devastating affect on the economic and social well being of the agricultural community. The average annual farm income country-wide 3 was £5,000. Locally the average income was £2,500 although many farmers had no income at all. Changes in the social and population structure of rural communities has threatened the position of the small family run farm. Whilst the family is the core unit of farming, families are no longer in a position to meet all their needs. Many are not ready to utilise ‘outside’ community resources such as health and social support services. There is a strong culture of stoicism and self -reliance. The local agricultural community is as a consequence experiencing significant hidden deprivation. This is illustrated by a decline in income, social exclusion, disadvantage in the housing market and limited education opportunities. 4. Key Health Findings 4.1 The agricultural community has a poor health profile and one that is worse than that experienced by non-farmers. Whilst there are individual farmers within the community who enjoy good health this appears not to be the common experience. 4.2 In the Tideswell survey, farmers reported an exceptionally high level of health problems, as measured by the EQ5D (a short self completion questionnaire for the measurement of health status). In many cases, most notably the pain/discomfort dimension, the prevalence of problems significantly exceeded even that reported by social classes IV and V in the national survey (Kind, 1998). This finding was repeated when the single EQ5D index score was analysed . 4.3 The commonly held view that farmers are stoic and self- sufficient was endorsed by the Tideswell survey which asked respondents to rate their own perception of their health. No significant difference between primary farmers and other occupational groups was found despite the higher level of ill health identified in the survey amongst the farming population. 4.4 Mental health is a significant expressed as well as normative need. In the Tideswell survey the observed prevalence of depression was almost twice as high among primary farmers than among secondary and non-farmers. The most worrying finding was the high prevalence of depression among male primary farmers - almost 8% reached the threshold for clinical caseness. The causes of mental ill health are complex and include rural isolation, financial worries and occupational problems. However the most significant stressor cited by farmers is the over burdening pressure of the increasingly complex paper work demanded by DEFRA. 4.5 Across the country farmers have a higher proportional mortality rate from suicide that the general population and suicide rates are expected to rise following the Foot and Mouth crisis. Almost 9% of farmers in the Tideswell survey had thought of suicide during the past year, it is 4 important to note that this includes almost one in five (18.5%) primary farmers in the age group 18-34 years. 4.6 The agricultural community experiences significant levels of musculoskeletal problems such as arthritis. Even young farmers reported chronic joint problems. 4.7 Occupational health related problems were important areas of expressed and felt need. They included musculo-skeletal injuries and health problems attributed to agri-chemical usage and zoonoses. 4.8 Nationally fatal injuries on farms rose by 20% over the last year. The high prevalence of accidents was regarded as inevitable by many members of the agricultural community. Although many conceded that a shortage of labour and time contributed to the high accident rate. 4.9 In all areas of health-care, access to preventative interventions, appropriate information, and treatment was a significant problem for the agricultural community. Cultural beliefs, social norms, stigma, distance decay, are the backcloth to these access problems. 4.10 Historically the healthcare providers have not viewed the agricultural community as a vulnerable population group and many are ignorant of socio-economic problems they face. As a consequence appropriate structures and mechanisms are not in place to deliver preventative Interventions, treatment or support, to meet the needs identified within this health needs assessment. Conclusion The indigenous population of the High Peak and Dales PCT is the agricultural community and it is the agricultural practices of this population that have shaped the geographical as well as socio/economic characteristics of the area. This health needs assessment reveals the significant hidden deprivation experienced by a large section of the farming community. It also identifies significant health needs most notably with regard to mental health and musculoskeletal problems. Despite the greater health problems experienced by the agricultural community they make less use of local health services than the local non- farming population. The 116 recommendations generated from this assessment offer public health solutions to the health needs identified. They are pertinent to the wider health and social care community and require a partnership approach if they are to be successful implemented. These recommendations are commended to High Peak and Dales Primary Care Trust for their consideration. 5 CONTENTS Page no. Executive Summary 3 1 Background 9 2 A Public Health Approach 9 3 Participatory Health Needs Assessment 10 3.1 Methodology 10 3.2 Listening events 11 3.3 Farmers gatherings 11 3.4 Focus group interviews 11 3.5 Tideswell health survey 12 3.6 Informal discussions 12 3.7 Health and Agriculture Conference 13 3.8 Participatory Needs Assessment Results 13 4 The Policy Context 13 5 The Geographical Setting 15 6 Rural Poverty and Deprivation 16 7 Demographic Profile of the Agricultural Community 17 8 Upland Hill Farming in High Peak and Dales PCT 18 8.1 Foot and mouth disease 2001 20 9 Social Support and Affiliations 22 9.1 The family 22 9.2 The church 24 9.3 Carers 24 9.4 Recommendations 25 10 Social and Leisure Activities 26 10.1 Families 26 10.2 Adults 27 10.3 Young farmers 27 10.4 Recommendations 28 11 Housing 28 11.1 Owner –occupier farmers 29 11.2 Tenant farmers 30 11.3 Recommendations 30 12 Income 31 12.1 Background 31 12.2 Local experiences 31 12.3 Recommendations 34 13 Education 35 13.1 Background 35 6 13.2 local experiences 35 13.3 Recommendations 36 14 Food and Farming 36 14.1 Background 36 14.2 Local Perspectives 37 14.3 Recommendations 38 15 Pesticides and Health 38 15.1 Background 38 15.2 Organophosphate Pesticides and health 39 15.3 Pesticide health and safety 39 15.4 Local perspectives 39 15.5 Access to expert health advice 40 15.6 Tideswell survey 41 15.7Recommendations 41 16 General Health 41 16.1 General health profile of High Peak and Dales residents 41 16.2 General health profile of Tideswell practice community 42 16.3 Recommendations 45 17.