Medical consequences of work-related accidents on 2 454 Swedish farms

Medical consequences of work-related accidents on 2 454Swedish farms. Scand J Work Environ Health 14(1988) 21-26. The medical consequences of accidents related to work on 2 454 farms in two Swedish rural municipalities were studied. The objectives were to describe the nature and scope of the injuries incurred, to collect data for the health plannin g procedure, and to test a local system for continuous injury surveillance in emergency care. All the injuries of 163 patients during the period I January - 31 December 1983 were analyzed with regard to diagnosis, severity, medical treat ment, hospitalization , and temporary and permanent disability. Wounds, contusions, fractures, foreign bodies, sprains, and strains constituted the main diagnostic groups. Injuries to the fingers, head and face (including the eyes), feet, and legs dominated. Six percent of the patients were admitted to the hospital. Seventy-five patien ts were put on temporary disability for a total of 2 431 d. For 62 of these patients the injuries were classified as minor. Permanent disability was observed in 4 070 of the cases. The study emphasizes the importance of registry criteria when one is comparing different injury surveillance sys tems. The majority of the injuries could have been prevented by the proper use of appropriate personal safetyequipment. The results may serve as a basis for general measures to improve local safety conscious ness.

Farm workers are exposed to a wide variety of hazards in their work . The medical consequences have been described particularly in the United States (2,12,13,24). To aid the improvement of the use of personal safety equipment among agricultural workers , knowledge of the type and location of injuries would be important. In addition activities which cause serious injuries requiring extensi ve medical treatment can be defined as a basis for local health planning. In Sweden the Health Act of 1983 states that the role of the county councils in this work is to provide data for injury control.
The objectives of the present study were (i) to describe the nature and scop e of farm work injuries in two Swedish rural districts, (ii) to collect data for the health planning procedure, and (iii) to test a local system for continuous injury sur veillance in emergency care.

Study area and population
The study was undertaken in two agricultural districts, Falkoping and Lidkoping in Skaraborg County, on 2 454 farms , corresponding to 27.8 1Il0 of all farms in the county and 2.1 % of all farms in Sweden. The two Reprint request s to: Mr BR Jansson , Department of Epidemiology and Pr eventive Medicine, Box 96054, S-541 06 Skovde, Sweden. districts participating in the study have district hospitals with surgical and medical specialist funct ions and emergency room s open 24 h a day . At the hospital s, there are also general emergency clinics, run by the local health centers , which are open between 1700 and 0800 from Monday to Friday and round the clock on weekend s and holidays . The health centers also ha ve standby medical services for emergency cases between 0800 and 1700 from Monday to Friday .
The study comprised all individuals living on farm s entered for both districts in the Agricultural Register. The patients should have consulted a doctor in the public health service for bodil y injury caused by an accident which had occurred on a farm in the area listed in the Agricultural Register during the period I January -31 December 1983. The population amounted to a total of 5 569 ind ividuals, 3 099 in Falkoping and 2 470 in Lidkoping (26).

Definitions
Afarm has been defined as a rural property consisting of five acres or more of arable land for the production of agricultural and forestr y products and listed in the Agricultural Register by Statistics Sweden (26).
Afarm work injury is an injury which has occurred on a farm in the area under study and on account of which the injured person has consulted a doctor in a public health facility. The injury should have occurred in connection with the production o f agricultural and forestr y products and to a person who lived on a farm in the study area and who participated in the work on the farm in a professional capacity.

Injury surveillance
All emergency cases, including injuries at public health institutions, were registered by the admissions staff on a special form. The form was divided into the four injury categories of home, work, traffic, and other (23). The forms containing a farm address were separated and manually checked against the entries in the Agricultural Register. Injuries which did not occur on a farm were excluded. Private pract itioners, dentists, and school and district nurses did not participate in the registration. A special inquiry showed that private practitioners did not handle any accident cases during the study period.

Classification
Information on diagnosis (25), parts of body injured, severity of the injury according to the Abbreviated Injury Scale (AIS) (3), external cause of the injury according to the E series (25), permanent disability , type of medical facility, outpatient treatment, number of consultations (including follow-up visits), hospitalization, and temporary disability was obtained from the patients' records. In 4.4 % of the emergency cases in the Falkoping district the admissions staff neglected to fill out the special form. For this reason, supplementary data collection was undertaken in the Lidkoping district by means of telephone interviews with persons on all I 086 farms, the response rate being 92.6 0/0 . Que stionnaires were mailed to the remaining 80 farm s, and 56 were filled out and returned. This checking pro cedure contributed an additional 23 work-related accidents (and eight nonwork-related accidents). They have been incorporated into the material.

Recall error
Recall error has been defined as limit ations in the memory capacity or experience of time. The postal questionnaire survey was checked through comparison of the reported accidents with the pati ent records. Two random samples (N = 282 and N = 200) from the Agricultural Register were used. Another eight workrelated accidents (and seven nonwork-related accidents) were found.

Statistical methods
The number of accidents can be cons idered the sum of the numbers of accidents in a large number of disjoint intervals of time . The probability of more than one accident within an interval tends towa rds zero when the length of the interval tends towards zero. By this consideration one can realize that the number of accidents of one individual, as well as of many individuals, has a distribution close to a Poi sson distribution, although one individual can contribute more than one accident. The hypothesis of no differences in incidence rate between two groups was tested with the optimal test for comparing two Poisson distributions (17).
Each age group (15-24, 25-34, 35-44,45-54, 55-64, and 65 years or older) was compared to all the others, men and women being combined . There was no significant correlation between age and accident risk .

Injuries
Altogether 163 work accidents causing 167 injuries were registered on 154 (6.3 %) of the 2454 farm s. The 163 accidents invol ved 142 men and 21 women, and six of these individuals were accident repeaters, three ha ving had two accidents and three ha ving had three accidents . Farm work injur ies represented 14.6 % of all the work injuries in the study area. Mechanical im- pact due to external trauma dominated (91 0/0) followed by overexertion of part of the body (7 %) and poiso ning and burns (2 %). The five main diagnoses (table I) were wounds (43 %), contusions (28 %), fractures (10 %), foreign bod ies (10 %), and sprains and strains (9 %) . Finger (24 %), skull and face including eyes (22 % ), and foot and leg (35 %) injuries dominate d ( figure 1). In 122 cases (73 %) the injured part of the body was not protected by personal protective equipment.

Severity
The severity of the injury was classified according to the Abbreviated Injury Scale, AIS score 1-6 (3 was performed, and the knee was immobilized in pIaster. The patient was hospitalized for 9 d an d put on full-time sick leave for thre e months .

Medical treatment
In all, 10 patients (6 %) were admitted to the hospital for a tot al of 258 (range 1-180) d. On e patient was trans ferred to the Department of Neurosurgery at the University Hospital in Goteborg for specialist treatment after a blow to the skull from a falling tree . A description of the case (given an AIS score of 4) follows: A 37-year-old farmer 's wife sustained a blow to the skull from a fallen branch while helping her husband fell trees. She had a lar ge wound on the scalp, a fracture through the ar ches of the first and second cervical vertebrae and subluxat ion between the seventh cervical vertebra and the first thoracic one , reduced sensibility below the second thoracic dermatome, complete mo tor deficit in the lower extremities, bladder paresis, and reduced strength in her right arm. Her functional capacity was permanently impaired. Seventy-three percent of all patients were brought for medical attention on the day the injury occurred. Out-patient treatment was given to 43 % at a surgical emergency room, to 37 % at a general emergency room, and to 20 % at a health center . Mo re than half (57 %) of the injuries were treated by general practitioners. The type of medical care is specified in table 2. The total number of outpatient consultations was 364

Methodology
The construction of the surveillance system permitted specification of the system coverage. Differences in the quality of registration between the two study areas were due to several factors. In the Falkoping district, the registration system was linked to a local intervention program. The registration was also used for checking that patient fees had been duly paid, two factors which probably increased the motivation for and exactness of registration in that area. More information and better planning of the work in the Lidkoping district may have counteracted these differences.
The system did not cover all farm-work injuries in the area. Some were probably dealt with by selftreatment and the district nurses. Pure dental injuries were not registered. Another 56 injuries were found in the Swedish Information System on Occupational Accidents and Diseases (lSA) at the National Board of Occupational Safety and Health (18). Accordingly the total number of reported farm-work injuries in the study area was 219, of which 59 % were reported only to the public health services, 25 % only to the national register, and the remaining 16 % was overlap, ie, found in both systems. At least 1 d of sick leave is required for inclusion in the Swedish national register. The local system in the area studied required at least one visit to an outpatient clinic or general practitioner. Over half of the patients treated by the outpatient health services were not put on sick leave. Cases were thus lost in both systems. Differences in registration criteria may explain these findings. A factor contributing to the differences may be that farm workers are less prone to consult a physician for minor injuries than other occupational groups in the community, because of longer distances to the hospital or a health center.
This study documents, at first sight, a similar farm accident rate for Michigan (22) and Skaraborg (table 5). However, there were differences in the definition of accidental injury, the data collection procedure, and the study periods. Nor was the level of exposure taken into account. The Swedish figures were not randomly selected; instead they represented all farms in the study area. When the incidence rate in Skaraborg is based on data from both the local and the national system, it increases to 89.2 per I 000 farms. The low rate for all of Sweden is probably a result of the special insurance rules for Swedish farmers, most not being paid for the first 3 d of sick leave. This procedure reduced the reporting levels to the national register (I8).
The most severe injuries (AIS scores of 2, 3, or 4) occurred in connection with forestry work. The

Temporary disability
Seventy-five patients were put on temporary disability for a total of 2 431 (range 1-360, average 32.5) d. The dominating activities were work with cattle and forestry work. Of the patients with temporary disability 62 out of 75 suffered from minor injuries (table 3). They accounted for 45 % of the total number of days of sick leave (mean 17.8 d per sick-listed patient). The following case illustrates an injury with an AIS score of I and sick leave of 75 d: A 38-year-old man twisted his right ankle on the steps of his barn. A radiograph showed a small apophysial fracture of the medial malleolus. He was given a plaster cast with a heel and put on full-time sick leave for 75 d. He had three consultations altogether. Table 5. A comparison of farm work accident rates between tile United States and Sweden.
-------------_ . material was too small to permit any generalization of this find ing. There may also be large fluctuations from year to year in local farm accident data. However, national sta tistics show that farmers in Sweden are over repre sented among fore str y work fatalities. The majority, 18 of the 19 fatalities in 1983 involved farmer s doing logging work. The corresponding figure for the period 1973-1985 was 64 0J0 (18). Our findings, together with the national stati stics, support the recommend ation that farmer -loggers be thoroughly informed about the importance of using personal safety equipment. It also seems important th at farmer-loggers participate in courses designed to teach farm ers sa fe work routines . Compulsory training in forestry work sho uld also be introduced .
The data in the medical records often failed to identify the cause of the accidents, as reported previously by Gallagher et al (6). The external cau se described by the E coding system (25) adds little to our understanding of the circumstances under which injuries occur (table 4). The present E coding system ha s limitations due to taxonomy, ie, an injury could be classified under several headings. In addition, it is not possible to classify the sequence of events and contributory factors related to human, agent, and environmental circumsta nces. The Committee on Trauma Research has emphasized the need for more adequate data in epidemiologic studies of injuries based on outpatient and inpatient data (4). The Nordic Committee of Sta tistic s (NOMESKO) has recommended a standardized manual for special studies (20).
The Abbreviated Injury Scale is recommended for measuring five separate criteria, ie, energy dissipation, thre at to life, permanent impairment, treatment period , and inciden ce (3). The construct validity of the Scale has been examined. Eastham questioned it as an indicator of the trauma-related recovery period and permanent disability (5). Huang & Marsh concluded that, of the four severity dimensions they reviewed, threat to life was essentially the sole dimension of severity measured by the Scale (10). Our finding s indicate that the Scale does not consider long-term effects such as the overall recovery period. This lack is demonstrated by the injuries classified as minor (AIS score I), which cau sed I lOl days (45 1110) of temporary disability.

Medi cal consequences
Thi s study demonstrates the yield of a system for continuous injury surveillance in Swedish emergency care . More than half (57 %) of the injuries were treated by general pra ctitioners. A large number of minor injuries and the increased availability of general practitioners may explain this result. Similar findings as regard s type of injurie s and treatment have been reported previously (8,19,21). The present result emphasizes the need for more intensive training in trauma care for general practitioners who plan to enter rural practi ce.
Minor injuries are not a great medical problem but are a handicap in agricultural work becau se of the risk of infection and pain in combination with the hea vy nature of the work . These injuries may also indirectly affect the farmer's finances if they occur in connection with spring sowing or harvesting. The pattern of injuries was heterogeneous; it reflected the varying nature and risks of agricultural work. Similar findings have been reported previously (2,9,12,13,24). As judged by the type and location of the injuries (table  I), appropriate personal protective equipment would probably reduce the number and severity of injuries related to farm work .
In a Finni sh study concerning the protective effect of safety equipment , the respondents claimed that loggers work more carefully if personal protective equipment is temporarily out of use (14). Consequently, the use of personal safety equipment could lead to greater risk-taking . This possibility should be taken into account when countermeasures are introduced.

Countermeasures
The injury surveillance system used in this study may serve as a basis for general measures to improve local safety consciousness, eg, information on the nature and scope of the problem. It also provides a basis for planning measures aimed at changing attitudes, eg, increasing the use of personal safety equipment. A third potential use for the system is the selectio n of priority fields for sa fety education, eg, forestry work. The system is not suitable as a basis for recommending technical measures such as improvements to sa fety devices on ma chines. However, the injury surveillance system used could be complemented by a technical investigation group in order to increase the understanding of the mechanisms behind accidental farm injuries.
We do not believe that farmers are ignorant of farm hazards. But it is difficult to recruit farmers to safety education (II) . One problem is that a farmer's mobility is frequently restricted by the needs of their animals and they often live a long way from the towns where the courses are held. Another is that only a minority of agricultural companies belong to the Swedish Farmers' Safety and Preventive Health Association (16). On the other hand much knowledge exists on farm hazards and sa fety (I, 15). The transfer of this knowledge to the farm ers is an important challenge for the future in order to promote health and safety.
A pre venti ve pro gram should be comprised of five sections, ie, mass communication, education, job safety analysi s, training , and supervision. An important ta sk before the implementation of such a program would be to identify factors which influence the use of safety measures and factors which limit safety practice or make it impossible (27).
Such a program of active safety measures must be combined with passive sa fety measures and improved equipment design. For example, in the forest industry, new timber-harvesting methods have been introduced which replace the manual tree-felling technique. The introduction of roll bars on tractors is an example of a passive safety measure which has decreased fatalities in Sweden during the last two decades (18).