The impact of a workplace cardiovascular health screening programme ‘Farmers Have Hearts’ on health behaviour change among Irish farmers

1 Introduction

Recent studies have identified Irish farmers as a high risk group for non-communicable diseases such as cardiovascular diseases (CVD) [1, 2]. Harmful lifestyle behaviours cause an estimated 80% of CVD cases [3]. However, CVD is also recognised as a ‘work-related’ condition and influenced by factors such as exposure to chemicals, long working hours, noise and stress [4]. Cardiovascular disease is linked to activity limitation [5], disability [6], acute occupational injuries [7], and musculoskeletal diseases [8]. The consequences of ill-health impact not only the wellbeing of farmers but also have financial implications. ‘Working identity’ has been found to be important among the farming community [9] and not being able to work due to ill-health or disability can be a cause of increased psychosocial distress [10]. Ill-health and absenteeism directly affect farm productivity, farm income and the environmental resource, and may also impact other farm family members who may need to provide care for ill family members or undertake additional farm work. Despite these far reaching impacts, male farmers are perceived to be a ‘hard to reach’ group in relation to engaging with health promotion interventions and preventive health behaviours.

Although contemporary health policy increasingly positions responsibility for lifestyle and health behaviours with the individual [11], targeting lifestyle and health behaviour change, in reality, is much more complex and challenging. Indeed, lifestyle and health behaviours are influenced by an array of factors, including the social and cultural context of people’s lives as well as the social determinants of health [12]. Whilst engaging so-called ‘hard-to-reach’ groups of men can be particularly challenging [13], these groups (including farmers) have been identified as a key target of men’s health policy within an Irish context [14]. Generally, men who adhere to more traditional constructs of masculinity tend to engage more often in unhealthy eating habits, smoking, drinking and risk taking [15, 16]. In an Irish and international farming context, the embodiment of a more typical rural masculinity revolves around more traditional family values, morality, landownership, hard labouring and farm work [9, 17] This can result in work and self-reliance being prioritised ahead of other matters, including health [18]. It has been proposed within a Canadian context, that farmers who transgress beyond the boundaries of more traditional masculine norms and roles, are likely to be stigmatised within the farming community [19]. These are important considerations at a time when Irish rural life, and the agricultural sector in particular, has experienced significant economic and social change, which has threatened the central pillars upon which Irish farm masculinities have been built [9].

It is well documented that adverse lifestyle and health behaviours are generally more prevalent among males from lower socio-economic status (SES) groups, which includes a high proportion of Irish farmers [20]. Within an Irish context, 88% of farm holders are male (21) and farmers typically live in more remote rural areas and have lower education levels [22]. Previous research has also established that rural living is associated with limited access to health services, higher living costs and fuel costs, fewer social services and limited access to social and leisure facilities [23]. These factors combined with attitudes associated with prevailing rural masculinity are likely to have many knock-on effects on farmers’ health, including their approach to lifestyle and health behaviours, seeking help and participation in health screenings. Clearly, Irish male farmers represent a priority population group in terms of targeting lifestyle and health behaviour change. Whilst there is emerging evidence of effective practice in engaging farmers [24], more research is needed regarding the mechanisms that might motivate or prompt farmers to change or modify lifestyle and health behaviours to improve health.

This study comprised two parts. It examined the impact of a workplace cardiovascular health check programme (Farmers Have Hearts - FHH), on lifestyle and health behaviour change. Secondly, it sought to explore what socio-demographic and health characteristics are associated with lifestyle and health behaviour change among farmers.

2 Methods

Ethical approval (Number 73/2013) was granted by the Ethics Committee of the Institute of Technology Carlow. The data for this male specific study were based on a convenience sample of farmers (n = 310) who took part in the FHH programme. The programme was carried out in four Irish counties: Longford, Cavan, Mayo and Cork. Recruitment for participants in the FHH programme was based on ‘self-referral’ of the farmers attending the livestock marts. Consent to participate was sought which included permission to copy and analyze each farmer’s cardiovascular screening results card (n = 310) and participation in a follow-up phone survey at Week 1 (n = 224) and Week 12 (n = 172). Some participants at baseline either did not respond or declined to take part in the follow-up phone surveys. This accounts for the lower response rate at Weeks 1 and 12. These follow-up phone questionnaires simultaneously functioned as a prompt to encourage lifestyle and health behaviour change among participating farmers. The cardiovascular screenings were conducted by qualified nurses from the Irish Heart Foundation and included several clinical and anthropometric tests to measure cardiovascular health (lipid profile, blood glucose, blood pressure, Body Mass Index (BMI) and waist circumference measurements). Assessment of risk factors for CVD was in accordance with European Guidelines on cardiovascular disease prevention in clinical practice [25]. Blood pressure was measured using a calibrated Omron M or Omron 7 device, after the participant had been seated for at least five minutes, with arm rested on a table at heart level. Tight clothing was removed from the upper arm. In cases of elevated blood pressure (≥140–159/90–99), the test was repeated on the other arm at a later time during the heart screening. A finger prick blood sample was used to gather a full lipid blood profile consisting of total cholesterol, HLD, LDL, triglycerides and blood glucose using a calibrated Alere Choltech LDX machine. These devices were checked prior to each usage using an optic check and were also subject to internal quality checks monthly using special controls provided by the supplier. Lipid readings that were taken as an indication of potential risk were: total cholesterol >5.0 mmol/L; HDL cholesterol <1.0 mmol/L; LDL cholesterol ≥3.0 mmol/L and Triglycerides ≥2.0 mmol/l Pre-booked participants were asked to fast but only 4.9% (n = 15) of the total sample reported having fasted before testing. In the case of non-fasting blood glucose levels, ≥7.0 mmol/L was considered at risk. Those participants with detected risk factors for CVD were referred to their GP by the nurse. This comprised a standardised letter for participants to give to their GP, which contained the cardiovascular health measurements from the health screening. The degree of urgency of the referral depended on the level of abnormality from the measurements taken during the health check. Height was measured without shoes or jackets and other heavy bulky clothing were removed for weight and waist measurements. BMI was calculated as weight in kilograms divided by the square of the height in metres (kg/m²) (World Health Organisation, 2015). A BMI kg/m² ≥25 was classified as overweight and a BMI kg/m² ≥30.0 as obese. A waist circumference ≥37 inches was classified as ‘at risk’ whist >40 inches was considered ‘high risk’ [26]. The health check measurements were recorded in a Results booklet, which all farmers received to take home.

Data on lifestyle behaviours, including smoking, alcohol consumption, levels of physical activity and stress, were also gathered during the cardiovascular screening. In addition, participating farmers received comprehensive and personalised lifestyle advice from the nurse, which addressed their detected cardiovascular risk factors. This was augmented by the provision of health information1 that included practical tips on how to changes health behaviours. All participating farmers received a specially commissioned booklet ‘Staying fit for farming’ [27] which, as well as offering practical tips on health behaviour change, sought to connect health with being a key driver of farm productivity.

Questionnaires (Appendix 1 and 2) were developed by the principal researcher and research supervisors and modelled on the Survey of Lifestyle, Attitudes and Nutrition in Ireland (Morgan et al., 2008). The Irish Heart Foundation health promotion team reviewed the questionnaires to ensure face-validity. Intended lifestyle and health behaviour change was measured using the Transtheoretical Model of Change [28], and documented by the first author. At Week 1, the focus was on pre-contemplation of behaviour change (based on responses to Question 13), whilst at Week 12, attention focused on actual behaviour change (based on responses to Question 1 and 1a). Follow-up use of GP services was also measured at Week 1 and Week 12 and the use of written health information was measured at Week 1. The principal researcher conducted the phone calls. The dates and times of calling were recorded. Up to four attempts were made, at different times and on different days, with messages being left when possible, before participants were deemed to be non-responders. All participants received the same standardised questionnaire. All data collected were recorded on a paper version of the questionnaire and manually entered into the Statistical Package for the Social Sciences (SPSS v22). A flowchart outlining the key stages of the study is provided in Appendix 3.

3 Results

The socio-demographic characteristics, as presented elsewhere [2], of this study group showed that the mean age of the participants was 52.90 (±12.70); the majority of farmers (72%; n = 161/223) were married, dry cattle and cattle rearing were the main reported farm enterprises (71%; n = 159/224) and over half of farmers (55%; n = 124/224) reported farming on a full time basis. Most respondents (82%; n = 183/224) reported having ‘some’ or ‘completed’ secondary level education. Almost one in two (46%; n = 140/303) farmers had high blood pressure (≥140/≥90 mmHg) and 46% (n = 140/303) had raised total cholesterol. One third of farmers were found to be obese (36%; n = 110/309) while 38% had a high risk waist circumference. These findings compare to an Australian study, which reported higher levels of abdominal obesity among farmers compared to the national average [33].

Less than one in five farmers (18%; n = 55/309) reported that they currently smoked. Almost half of farmers (46%; n = 142/306) reported that they consumed alcohol on a weekly basis with 25% (n = 35/142) of ‘drinkers’ reporting consumption of >17 standard drinks or more weekly. The vast majority (95%; n = 293/307) of participants reported being involved in occupational physical activity, whilst two-thirds (63%; n = 192/306) reported being physically active (≥5 days a week and for ≥30 minutes or more on active days) outside of work. One in six farmers (16%; n = 49/302) reported that they felt stressed ‘often’ or ‘most of the time’. The accumulation of multiple risk factors for CVD, based on objective and self-reported health measures, showed that the vast majority (81%; n = 255/310) of farmers had 4 or more CVD risk factors out of twelve risk factors observed.

Referral information was available for 92% (n = 285) of the analysed results cards (Table 1). Although 79% (n = 226) of farmers received a standardised letter of referral from the nurse advising them to visit their GP, just 15% (n = 25) of those referred by the nurse reported having done so at Week 1. Interestingly, at Week 1, 33% (n = 47) of those who had been given a letter of referrals reported not having been referred. At Week 12, an additional 47 participants who reported not having visited their GP by Week 1, reported having done so in the intervening period. In total, 32% (n = 72) of participants who were referred by the nurse reported having acted on this advice and visited their GP.

At Week 1, the majority of farmers 74% (n = 166/224) reported contemplating some change(s) to their lifestyle behaviours to improve their health (Table 2). Almost 64% (n = 106/166) reported considering changing their diet, whilst 35% (n = 58/166) reported thinking about increasing their level of physical activity. Among ‘smokers’, 56% (n = 15/27) reported thinking about cutting down or stopping smoking, while just 12% (n = 9/74) of ‘drinkers’ reported thinking about cutting down on or stopping their drinking. At Week 12, 48% (n = 83/172) reported having made some changes to their lifestyle behaviours, most notably by having increased their level of physical activity (93%; n = 77/83) and/or made changes to diet (89% ’ n = 74/83). Of ‘smokers’ 36% (n = 5/14) reported having either stopped or reduced the number of cigarettes smoked per day, whilst 29% (n = 11/38) of ‘drinkers’ reported having cut down or stopped drinking. The majority of farmers (65%; n = 53/81) who reported having made changes to their health behaviours also reported noticing a positive change to their health and wellbeing. Among the reported reasons for not adopting health behaviour changes were ‘not having sufficient reason to change’ and ‘not being bothered with health’.

An analysis of the socio-demographic and health factors behaviour showed that age, education level, total cholesterol levels, LDL levels and alcohol units per week were associated with contemplating (Table 3) and making (Table 4) lifestyle behaviour change. The odds of contemplating lifestyle behaviour change were significantly higher among farmers aged ≥65 (P. 028, OR 3.062, 95% CI 1.126–8.332) and 45–64 years (P. 033, OR 2.490, 95% CI 1.076–5.765) compared to the indicator category (18–44 years). Farmers who had a total cholesterol ≥5.1 mmol/l (OR 0.439, 95% CI 0.230–0.838) had significantly (P. 013) lower odds of contemplating lifestyle behaviour change compared to farmers from the indicator category (total cholesterol ≤5.0 mmol/l). Farmers with LDL levels of ≥3.1 mmol/l (OR 0.472, 95% CI 0.243–0.917) were significantly (P. 027) less likely to report contemplating lifestyle behaviour change compared to farmers from the indicator category (LDL levels ≤3.0 mmol/l). No significant relationship was found between making changes to lifestyle behaviour and socio-demographic characteristics. Among the health characteristics that were associated with making lifestyle behaviour changes were BMI and waist circumference. The odds of making changes to lifestyle behaviours to improve cardiovascular health were significantly (P. 041) less likely among farmers with a BMI kg/m² ≥25 (OR 0.349, 95% CI 0.133–0.917) compared to the indicator category (BMI kg/m² ≤24.9), while farmers with waist measurements of ≥94 cm (OR 0.375, 95% CI 0.167–0.840) were significantly (P. 017) less likely to make changes to lifestyle behaviours compared to farmers from the indicator category (<94 cm).

In terms of their use of health information, 54% (n = 120/222) reported having ‘scanned through’ or ‘read’ the health information booklets. The most frequently read booklets were reported to be ‘Healthy eating’ (45%; n = 54/119) and ‘Managing your cholesterol’ (39%; n = 46/119). Almost 50% (n = 64/129) of farmers said they could recall a key message from the booklets, mostly relating to ‘healthy eating’ (36%; n = 23/64) and ‘stress management’ (16%; n = 10/64).

This is the first Irish study to have investigated the impact of a workplace cardiovascular health check programme as a catalyst for lifestyle and health behaviour change among farmers, although there has been some international work in this area [24]. The study showed that the majority of farmers reported contemplating behaviour change at Week 1, with almost half reporting having made some changes at Week 12. Increased physical activity was the most frequently reported change in behaviour. This is noteworthy as farming is typically seen, not least by farmers themselves, as a highly active profession. Previous studies have found that men are more likely to increase their physical activity than to change other health behaviours [34]. This can also be motivated by notions of traditional masculinity and the desire to appear ‘strong and muscular’ rather than by the desire to improve health [35]. Adopting a healthier diet was the next most frequently reported change. This is somewhat surprising as more traditionally masculine men tend to associate healthy food as ‘bland’ and ‘boring’ [36], healthy eating as being ‘weak’ and therefore not something to which one should ‘admit’ [37]. Nevertheless, against a backdrop of a high prevalence of obesity among farmers in this study and elsewhere [33, 38], the potential of workplace interventions such as that reported in this study to impact on dietary and physical activity behaviour, warrants further consideration and investigation. The reported changes made to smoking and drinking behaviours in this study were less positive. Less than a third of farmers whose weekly alcohol consumption exceeded >17 standard drinks, reported having altered their drinking patterns at Week 12. Similarly, one-third of ‘smokers’ reported having reduced or quit smoking. These figures should be interpreted with caution, however, due to the low response rates. Previous studies have found that SES is a barrier to changing smoking and drinking habits [39]. There are mixed findings in relation to the impact of health screenings on smoking and drinking behaviours, although an Australian study found that health promotion interventions based on social activities and health screenings were successful in addressing these habits among farmers and fishermen [40]. Age (≥45), total cholesterol and LDL were found to be significantly associated with prompting contemplation of behaviour change among farmers. Older farmers (≥65) were most likely to contemplate health behaviour change. Age was, however, not associated with transitioning from contemplation to actual health behaviour change. Although health behaviour change is associated with improved health outcomes among older people, evidence suggests that this group finds it harder to adopt behaviour change[41].

This study also examined what socio-demographic and health characteristics were associated with lifestyle and health behaviour change (at both ‘contemplation’ and ‘action’ stages). Although all farmers received the same brief health intervention and personalised lifestyle advice, findings suggest that older farmers are more likely to contemplate changes to health behaviours to improve cardiovascular health. It is recommended that the focus of future interventions should be targeted at the age group 45–64 years, providing appropriate follow-up interventions and supports to make the transition from contemplating to following through with lifestyle behaviour change. To reach this group, interventions need to account for key factors that influence farmers’ views on health, including community-based support [42], adopting a gender-specific approach which acknowledges prevailing norms of rural masculinities, as well as the importance of farmers’ ‘working identity’ (9). This is underpinned by international research [43].

Furthermore, there is a need for a different focus on lifestyle behaviour change for younger farmers (18–44 years). Risk factors for CVD develop in the early years of life and health behaviour changes can lead to increased life years and to the prevention of ill health. A stronger focus on primary prevention among younger farmers in relation to CVD is recommended.

Findings shown that participants with higher cholesterol levels and higher LDL levels; i.e. those most in need of health behaviour change; were least likely to contemplate health behaviour change compared to those with ‘healthy’ total cholesterol and LDL levels. This, despite participants being warned of the particularly adverse effects of elevated LDL levels by the nurses during the cardiovascular screening. Characteristics that were found to be significantly associated with making health behaviour change included BMI and waist circumference. However, those farmers who were classified as overweight/obese and/or as having an ‘at risk’ waist circumference, were significantly less likely to report health behaviour change than those with a ‘healthy’ BMI or a ‘healthy’ waist circumferences. This is of interest as being overweight or obese is associated with occupational farm injuries due to falls and cattle handling [44]. It is well established that changing behaviour is a complex process influenced by factors such as intentions, motivations and personal beliefs [45, 46]. The intention to change behaviour does not automatically translate into action [45]. There are several theories why these intentions are not always successful. Self-efficacy, the perception and belief that one is capable of changing certain behaviours, is one of these theories [46]. Evidence from this study suggests that, in the absence of follow-up lifestyle interventions or other measures to support farmers with lifestyle behaviour change, farmers may not feel empowered to initiate such change. It has been argued that self-efficacy is the key driving factor of behaviour change rather than the knowledge that behaviour change will improve one’s health status [47]. The majority of farmers (65%) reported having noticed a positive health effect after incorporating changes to their health behaviours. The use of testimonials from such farmers might be a useful source of motivation or inspiration for other farmers to dolikewise.

The majority of farmers were referred to their GP by the nurses as a result of the cardiovascular health screenings. In total, almost one-third of farmers reported having acted on this advice and had gone to see their GP. It is a source of real concern that two-thirds of farmers did not act on this advice. Nevertheless, in the context of farmers being a HTR group to engage with health inventions (48), it can also be argued that this finding is encouraging. The noncompliance of the remaining participants with a follow-up visit to their GP could be explained by a general reluctance to visit a GP, downplaying of symptoms, unwillingness to take time off work and costs [11]. Misunderstanding of health instructions could be also a reason for non-adherence to referral advice. For example, findings from the Sustainable Farm Families Train the Trainer model showed that factors such as the level of engagement of the nurse, interactivity and knowledge of farming context contributed to more farmer centred health care delivery [49].

Although these results show that the cardiovascular screenings were an effective tool for some farmers to visit their GP; clearly, more prompting and follow-through is needed to encourage the more reluctant farmers to do likewise. It was noteworthy that one-third of referred farmers reported not having been referred to their GP during the cardiovascular screening. Misunderstanding of health messages is common among people with lower levels of health literacy [50] as well as farmer ‘unfriendly’ working practices [49] often results in noncompliance. Based on socio-demographic characteristics of participating farmers (lower SES, lower education levels, rural men, older age), it is to be expected that familiarity with cardiovascular health terminology and their levels of health literacy would have been low. Consequently, the communication of health messages may need to be adjusted to the comprehension level of farmers. This study bears out the significance of this; given that many of those farmers who were referred but did not go to their GP, were in need of further medical examination or treatment in relation to their risk for CVD.

One-third of farmers reported having scanned through or read some health information booklets they received during the health checks. Of those who reported having read the booklets, one in two did not recall any key message from the booklets. Research suggests that the uptake of health informationbooklets could be improved by being more tailored to the target group mind set and to health literacy levels [51].

5 Conclusion

The FHH programme for farmers at livestock marts was successful on a number of levels. The programme reached beyond the ‘worried-well’ and also reached a ‘hard-to-reach group of men (middle aged men, farmers, lower SES, lower education, rural men); almost one-third of farmers visited their GP as a direct result of the cardiovascular screening; and almost half of farmers reported having made at least one health behaviour change at Week 12. The intervention was limited to a once-off cardiovascular health screening – the absence of any community-based follow-up supports, such as specific lifestyle interventions or lifestyle advice, peer supports or prompts to encourage health behaviour change, is likely to have made it more challenging for farmers to change health behaviours. Farmers need to be supported to be more proactive in addressing health behaviours, particularly in the areas of weight loss, quitting smoking and reducing alcohol consumption – areas in which this study found farmers to be least proactive. Addressing these lifestyle behaviours warrant action as obesity, smoking and drinking are a major risk for CVD and for occupational injuries.

This study acknowledges some limitations in relation to the results. Farmers with greater health problems are unlikely to have been captured in the study as it is assumed that they are no longer actively working and consequently not attending marts (‘healthy worker’ effect). There was no comparison group of farmers; therefore, findings cannot be compared to a group which did not have exposure to cardiovascular health screenings. The study population was based on convenience sampling and therefore the results may not be generalizable to the farming population as a whole. Self-reported lifestyle and health behaviour relied on participants providing honest and reliable responses and these measures should therefore be treated with caution. The same researcher collected data at baseline and follow-up, which could have constituted potential bias. There was a lack of follow-up support for farmers who were experiencing difficulties in relation to lifestyle and behaviour change. Despite these limitations, this study provides valuable insights into engaging farmers in their health and the potential of a workplace health intervention to act as a catalyst for health behaviour change in Irish farmers. Future interventions ought to give due regard to the complexity of health behaviour change, to providing increased follow-up and community based supports and adhering to principles of best practice in engaging hard to reach men in health interventions.

Conflict of interest

None to report.