Occupational injuries and safety systems for prevention in South Korean agriculture

Kokoteksti

(1)PUBLICATIONS OF THE UNIVERSITY OF EASTERN FINLAND. As an act for farmers’ occupational injury and disease prevention was passed in 2016, demands for regulations have increased in Korea. This thesis aimed to explore the scale of occupational injury and suggest a direction for developing regulations. The results from the survey showed that 3.6% of farmers experienced farm-work related nonfatal injuries in 2012. Safety system errors should be reviewed by injury type and items suggesting system improvement should be developed based on the analysis.. uef.fi PUBLICATIONS OF THE UNIVERSITY OF EASTERN FINLAND Dissertations in Health Sciences. ISBN 978-952-61-3796-4 ISSN 1798-5706. DISSERTATIONS | HYOCHER KIM | OCCUPATIONAL INJURIES AND SAFETY SYSTEMS FOR PREVENTION... | No 626. HYOCHER KIM. Dissertations in Health Sciences. HYOCHER KIM. OCCUPATIONAL INJURIES AND SAFETY SYSTEMS FOR PREVENTION IN SOUTH KOREAN AGRICULTURE.

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(3) OCCUPATIONAL INJURIES AND SAFETY SYSTEMS FOR PREVENTION IN SOUTH KOREAN AGRICULTURE. 1.

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(5) Hyocher Kim. OCCUPATIONAL INJURIES AND SAFETY SYSTEMS FOR PREVENTION IN SOUTH KOREAN AGRICULTURE. To be presented by permission of the Faculty of Health Sciences, University of Eastern Finland for public examination on June 10th, 2021, at 12 o’clock noon. Publications of the University of Eastern Finland Dissertations in Health Sciences No 626 Institute of Public Health and Clinical Nutrition University of Eastern Finland, Kuopio 2021. 3.

(6) Series Editors Professor Tomi Laitinen, M.D., Ph.D. Institute of Clinical Medicine, Clinical Physiology and Nuclear Medicine Faculty of Health Sciences Professor Tarja Kvist, Ph.D. Department of Nursing Science Faculty of Health Sciences Professor Ville Leinonen, M.D., Ph.D. Institute of Clinical Medicine, Neurosurgery Faculty of Health Sciences Professor Tarja Malm, Ph.D. A.I. Virtanen Institute for Molecular Sciences Faculty of Health Sciences Lecturer Veli-Pekka Ranta, Ph.D. School of Pharmacy Faculty of Health Sciences Distributor: University of Eastern Finland Kuopio Campus Library P.O.Box 1627 FI-70211 Kuopio, Finland www.uef.fi/kirjasto Name of the printing office GRANO, 2021 ISBN: 978-952-61-3796-4 (print) ISBN: 978-952-61-3797-1 (PDF) ISSNL: 1798-5706 ISSN: 1798-5706 ISSN: 1798-5714 (PDF). 4.

(7) Author’s address:. Rm. 410, Nongsaemyungro 310 Agricultural Engineering Department Rural Development Administration JEONJU SOUTH KOREA. Doctoral programme:. Doctoral Programme in Health Sciences. Supervisors:. Professor emeritus Kimmo Räsänen, M.D., Ph.D. Institute of Public Health and Clinical Nutrition University of Eastern Finland KUOPIO FINLAND Dr. Aoife Osborne. BAgrSc, Ph.D. School of Agriculture and Food Science University College Dublin DUBLIN IRELAND. Reviewers:. Docent Janne Karttunen, Ph.D. TTS Work Efficiency Institute NURMIJÄ RVI FINLAND Dean, Professor Yong Heo, D.V.M., Ph.D., DKcLAM, DKBT Department of Occupational Health Daegu Catholic University DAEGU SOUTH KOREA. Opponent:. Professor Peter Lundqvist, Ph.D. Department of Work Science, Business Economics and Environmental Psychology Swedish University of Agricultural Science ALNARP SWEDEN. 5.

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(9) Kim, Hyocher Occupational injuries and safety systems for prevention in South Korean agriculture Kuopio: University of Eastern Finland Publications of the University of Eastern Finland Dissertations in Health Sciences 626. 2021, 88 p. ISBN: 978-952-61-3796-4 (print) ISSNL: 1798-5706 ISSN: 1798-5706 ISBN: 978-952-61-3797-1 (PDF) ISSN: 1798-5714 (PDF). ABSTRACT Farm-work related injuries have been studied and managed in a variety of ways for several decades in Western countries. Specialized research and management on farmers' occupational injury was not actively conducted until 2000s in South Korea, however. As the Act on Farmers’ and Fishers’ Occupational Injury and Disease Insurance and Prevention was finally passed in 2016 as the result of experts' persistent effort, demands to develop intervention programs, regulations, and guidelines to prevent farm-work related injury have increased. The purposes of this thesis were to explore the scale and attributes of occupational injury in farmers in South Korea, investigate risk factors and root causes of farm-work related injury, and suggest a direction for developing checklists and relevant regulations to use in future agricultural safety intervention programs. Results from The Korea National Health and Nutrition Examination Survey (KNHANES) IV data for 3 years from 2007 through 2009 showed that the injury rate in skilled agricultural, forestry, and fishery workers (7.7%) was second only to craft, equipment, machine operating, and assembly workers (10.6%). To investigate the scale and attributes of farm-work related injury, data from the Korea Farmers’ Occupational Disease and Injury Survey (KFODIS) was used. In the 2013, 16,160 farmers age 19 or older were surveyed across 10,020 farms in 334 cities and counties. The results showed that 3.6% of farmers experienced farmwork related nonfatal injuries requiring outpatient or inpatient treatment in 2012.. 7.

(10) Farm-work related injury was associated with age, farm ownership, and night-time working experience at statistically significant levels in the univariate analysis results. Using the logic tree diagramming method, 194 root causes were identified in 68 farm-work related injuries. Deriving root causes of occupational injury and classifying them as errors in safety systems revealed that farm-work related injury in South Korea occurred as a result of a combination of errors in a variety of systems, such as inadequate safety design and workplace maintenance/preparation, as well as insufficient safety training and the underuse of PPE. The four checklists developed in Finland, Ireland, ILO and EU-OSHA were analyzed using safety systems and subsystems. Across all checklists, the items classified into the training/procedures system were the most common with a proportion of 32.5%, followed by the mitigation system (18.2%), the maintenance/preparation system (14.3%), the design system (8.2%), the human factor system (5.6%), and the warning/notification system (4.2%). To develop effective agricultural safety and health checklists and relevant regulations in the future, safety management items should not be biased toward a particular system of safety. Rather, safety system errors confirmed in the field should be reviewed by agricultural injury type and items suggesting system improvement should be developed on the basis of the analysis. National Library of Medicine Classification: WA 440, WA 485 Medical Subject Headings: Occupational Injuries/prevention and control; Agriculture; Farmers; Safety Management; Risk Factors; Republic of Korea Keywords: Farm-work, Injury, Safety system, Prevention, South Korea. 8.

(11) Kim, Hyocher Työ peräiset vammat ja ehkäisevät turvallisuusjärjestelmät Etelä-Korean maataloudessa Kuopio: Itä-Suomen yliopisto Publications of the University of Eastern Finland Dissertations in Health Sciences 626. 2021, 88 s. ISBN: 978-952-61-3796-4 (print) ISSNL: 1798-5706 ISSN: 1798-5706 ISBN: 978-952-61-3797-1 (PDF) ISSN: 1798-5714 (PDF). TIIVISTELMÄ Länsimaissa maatalouden työ peräisiä vammoja on tutkittu ja pyritty hallitsemaan monin tavoin jo vuosikymmenten ajan. Etelä-Koreassa maatalouden työ peräisten vammojen tutkimusta ja hallitsemista ei kuitenkaan ole aktiivisesti toteutettu ennen 2000-lukua. Vuonna 2016 säädettiin laki maanviljelijö iden ja kalastajien työ peräisten vammojen ja ammattitautien vakuuttamisesta ja ehkäisystä asiantuntijoiden pitkäkestoisten ponnistelujen pohjalta. Samanaikaisesti vaatimukset interventio-ohjelmien, säännö sten ja ohjeistusten saamiseksi maatalouden työ peräisten vammojen vähentämiseksi ovat lisääntyneet. Tämän väitö skirjan tarkoituksena oli tutkia maatalouden työ peräisten vammojen määrää ja laatua Etelä-Koreassa, selvittää niiden riskitekijö itä ja juurisyitä sekä ehdottaa suuntaviivoja työ turvallisuuden tarkastuslistojen sekä säännö sten kehittämisestä tulevien maatalouden turvallisuusinterventioiden tueksi. The Korea National Health and Nutrition Examination Survey (KNHANES) IV tulokset vuosilta 2007-2009 osoittivat, että työ peräisten vammojen esiintyvyys (7,7 %) oli toiseksi suurin ammattimaisen maatalouden, metsätalouden ja kalastuksen työ ntekijö illä. Suurin esiintyvyys (10,6 %) oli käsityö läisillä, varustelu-, koneenkäyttö - ja kokoonpanotyö ntekijö illä. Maatalouden työperäisten vammojen määrää ja laatua tutkittiin Korea Farmers’ Occupational Disease and Injury Survey (KFODIS) aineistosta. Aineisto, jossa oli 16160 yli 19-vuotiasta maanviljelijää kerättiin 10020 maatilalta 334 kaupungissa ja maakunnassa vuonna 2013. Tulosten mukaan 3,6 prosentilla osallistujista oli ollut vuonna 2012 maataloustyö hö n liittyvä polikliinista tai sairaalahoitoa vaatinut eikuolemaan johtanut työ peräinen vamma. Maataloustyö stä johtunut vamma oli. 9.

(12) yhden muuttujan analyysissa tilastollisesti merkitsevästi yhteydessä vastaajan ikään, maatalouden omistajuuteen sekä yö työ hö n. Logic tree diagrammi -menetelmällä lö ytyi yhteensä 194 juurisyytä vamman synnylle 68 analysoidusta maatalouden työ peräisestä vammasta. Luokittelemalla juurisyyt turvallisuusjärjestelmän virheiksi todettiin, että maatalouden työ peräiset vammat syntyivät virheiden yhdistelmistä useissa turvallisuusjärjestelmän osioissa, kuten riittämättö mässä turvallisuussuunnittelussa, työ paikan kunnossapidossa/valmistelussa sekä riittämättö mästä turvallisuuskoulutuksesta ja henkilö suojainten käytö stä. Tutkimuksessa analysoitiin turvallisuusjärjestelmän osajärjestelmien mukaisesti neljä maataloustyö n työ turvallisuuden tarkastuslistaa, jotka oli kehitetty Suomessa ja Irlannissa sekä ILO:n ja EU-OSHA:n toimesta. Tavallisimpia kohteita olivat koulutus-/menettelytapajärjestelmä (32,5 %), joiden jälkeen seurasivat altistumisen vähentäminen (18,2 %), kunnossapito-/valmistelujärjestelmä (14,3 %), suunnittelujärjestelmä (8,2 %), inhimillinen tekijä (human factor) järjestelmä (5,6 %) sekä viimeisenä varoitus-/ilmoitusjärjestelmä (4,2 %). Jotta maatalouden työ turvallisuuden tarkastuslistoja ja säännö ksiä voidaan tulevaisuudessa kehittää mahdollisimman relevanteiksi, turvallisuusjohtamisen kohteet eivät saa olla yksipuolisesti turvallisuusjärjestelmän tiettyihin osajärjestelmiin kohdentuvia. Turvallisuusjärjestelmässä käytännö ssä todettuja virheitä pitää tarkastella niistä aiheutuvien maatalouden työ peräisten vammojen tyypin mukaan ja turvallisuusjärjestelmää pitää kehittää perustuen näihin analyyseihin. Yleinen suomalainen ontologia: maataloustyö ; työ tapaturmat; työ turvallisuus; Korean tasavalta Avainsanat: maataloustyö , vamma, turvallisuusjärjestelmä, ennaltaehkäisy, EteläKorea. 10.

(13) ACKNOWLEDGEMENTS This Ph.D. work was caried out based on the international cooperation project between Rural Development Administration (RDA) and the Institute of Public Health and Clinical Nutrition, School of Medicine, Faculty of Health Science, University of Eastern Finland. Also, data used in the thesis was made through several projects conducted by RDA. I would like to express my deepest gratitude to Professor emeritus Kimmo Räsänen. His expertise, trust, patience and attitude not only for this work but also life itself have been a great support and guidance to me. There were lots of things that I really want to thank him for in not only university but also cottage, Kuopio and Korea. It is not possible for me to enumerate every moment he gave me favors. I hope that we could meet in Finland or Korea near future, talking and enjoying some beers (but not Vodka) with sauna. Also, I warmly thank his beautiful and tender-hearted wife, Marita. Her gift (the Muumi cup) is still one of my daughter’s favorite stuffs and her warm hug before going back to Sweden in 2019 gave me a great motivation for this work. I, also, express my thanks to Dr. Aoife Osborne for her valuable comments with the manuscript of the thesis. I sincerely thank my pre-examiners Dr. Janne Karttunen of Work Efficiency Institue and Dean Yong Heo of Daegu Catholic University for their comments and suggestions that improves this Ph.D. work I would like to acknowledge Dr. Kyungsuk Lee and researcher, Hyeseon Chae of RDA, who have been my boss and colleague respectively and to whom I will always be in debt for their valuable support. Furthermore, I am sincerely thankful for the support I received from my superiors and colleagues, Vice Administrator of RDA Dr. Dooho Kim, Dr. Kyungran Kim, Dr. Kyungsu Kim and other teammates in RDA. My gratitude goes to my friends, Jeonguk Heo, Kiin Choi, Minsuk Kim, Jaewon Lee, Hyungeun Kim, Jungmi Choi, Hyojin Kim and two Dr. Sangbeom Kim for their friendship and support in Korea. Most importantly, my warmest thanks go to my mother, Soonja Jung, wife, Hyesun Lee, daughter, Taelynn Kim, and sister, Deokeun Kim who stayed in South Korea during my studying in Finland. This work would not have been possible without my family’s support and sacrifice. Anyhow, this work will become a turning point in my life. And, I will do my best for my family and farmers’ health and safety as before. Jeonju, 7 May 2021 Hyocher Kim. 11.

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(15) LIST OF ORIGINAL PUBLICATIONS This dissertation is based on the following original publications: I. Kim, S.-K., Kim, H., Lee, K., Kang, H.-T., Oh, S.-S., & Ko, S. B. (2014). The Relationship between Injury and Socioeconomic Status in Reference to the Fourth Korean National Health and Nutrition Examination Survey. Annals of Occupational and Environmental Medicine, 26(1), 1.. II Kim, H., Räsänen, K., Chae, H., Kim, K., Kim, K., & Lee, K. (2016). Farm WorkRelated Injuries and Risk Factors in South Korean Agriculture. Journal of Agromedicine, 21(4), 345–352. III Kim, H., Lee, K., & Räsänen, K. (2016). Agricultural injuries in Korea and errors in systems of safety. Annals of Agricultural and Environmental Medicine, 23(3), 432–436. IV Kim, H., Räsänen, K., Chae, H., & Lee, K. (2018). Analysis of checklists for agricultural safety management. Annals of Agricultural and Environmental Medicine, 25(3), 494–499.. The publications were adapted with the permission of the copyright owners.. 13.

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(17) CONTENTS ABSTRACT ............................................................................................................ 7 TIIVISTELMÄ ......................................................................................................... 9 ACKNOWLEDGEMENTS ..................................................................................... 11 1 INTRODUCTION ............................................................................................ 19 2 REVIEW OF THE LITERATURE ....................................................................... 21 2.1 THE INTRODUCTION OF AGRICULTURE AND RURAL SOCIETY IN SOUTH KOREA............ 21 2.1.1 General characteristics of agriculture and rural society ................ 21 2.1.2 The attributes and changes of agriculture ....................................... 21 2.1.3 Structural change and aging in rural society and farming ............. 22 2.2 REVIEW OF OCCUPATIONAL INJURY IN AGRICULTURE RESEARCH .......... 23 2.2.1 Occupational injury rates in agriculture ........................................... 23 2.2.2 Type and source of farm-work injuries ............................................ 26 2.2.3 Increase of occupational injury and disease in farmers and change in agricultural policy .................................................................................... 27 2.2.4 Risk factors for farm-work injuries .................................................... 28 2.3 REVIEW OF OSH MANAGEMENT IN AGRICULTURE .................................... 29 2.3.1 OSH system in South Korea ............................................................... 29 2.3.2 3Es intervention programs (Education, Engineering and Enforcement) .... 31 2.3.3 Farm-work related injuries and safety systems .............................. 32 3 AIMS OF THE STUDY ..................................................................................... 35 4 SUBJECTS AND METHODS ............................................................................ 37 4.1 RELATIONSHIPS BETWEEN INJURIES AND TYPE OF OCCUPATION, INCLUDING AGRICULTURE ............................................................................ 37 4.1.1 Study sample: Korea National Health and Nutrition Examination Survey (KNHANES) participants ........................................................................... 37 4.1.2 KNHANES variables ............................................................................. 38 4.1.3 Statistical methods .............................................................................. 39 4.2 FARM WORK–RELATED INJURIES AND RISK FACTORS IN KOREA (STUDY II)..................39 4.2.1 Study sample: Korea Farmers’ Occupational Disease and Injury Survey (KFODIS) participants .............................................................................. 39 4.2.2 KFODIS variables ................................................................................. 42 4.2.3 Statistical methods .............................................................................. 42 4.3 FARM-WORK RELATED INJURIES AND ERRORS IN SAFETY SYSTEMS (STUDY III)...... 42 15.

(18) 4.3.1 Sample: Injury claims records ............................................................ 42 4.3.2 Identifying safety system errors ........................................................ 44 4.4 ANALYSIS OF CHECKLISTS FOR AGRICULTURAL SAFETY MANAGEMENT (STUDY IV) ........45 4.4.1 Checklist search ................................................................................... 45 4.4.2 Categorizing safety system items ...................................................... 46 5 RESULTS ........................................................................................................ 49 5.1 RELATIONSHIPS BETWEEN INJURY AND TYPE OF OCCUPATION IN KOREA (STUDY I).. 49 5.2 FARM-WORK INJURIES AND RISK FACTORS (STUDY II) .............................. 51 5.3 FARM-WORK INJURIES AND SAFETY SYSTEM ERRORS (STUDY III) ........... 55 5.4 ANALYSIS OF SAFETY SYSTEM CHECKLISTS (STUDY IV) ............................. 60 6 DISCUSSION .................................................................................................. 63 6.1 DISCUSSION OF THE RESULTS ...................................................................... 63 6.1.1 Relationship between injury and type of occupation ..................... 63 6.1.2 Occupational injuries and risk factors in agriculture ...................... 64 6.1.3 Occupational injuries and safety system errors.............................. 68 6.1.4 Suggestions for checklist and regulation development ................. 71 6.1.5 Ethical considerations ......................................................................... 74 6.2 STRENGTHS AND LIMITATIONS OF THE STUDY ......................................... 75 6.2.1 Strengths of the study ........................................................................ 75 6.2.2 Study limitations .................................................................................. 76 7 CONCLUSIONS .............................................................................................. 79 REFERENCES ....................................................................................................... 81. 16.

(19) ABBREVIATIONS CI. Confidence Interval MOHW Ministry Of Health and. EU-OSHA European Agency for Safety. FOHS. Welfare. and Health at Work. MAI. Mutual Aid Insurance. Farmers' Occupational. NACF. Nation Agricultural. Health Services. Cooperation Federation. FSI. Farmers’ Safety Insurnace. NC. Not Categorized. HAS. Health and Safety Authority. NMI. Need More Information. HOCs. Hierarchy Of Controls. OSH. Occupational Safety and Health. ILO. International Labour Organization. KFODIS Korea Farmers’ Occupational. OR. Odds Ratio. PPE. Personal Protective. Disease and Injury Survey KNHANES Korea National Health and. Equipment RDA. Nutrition Examination Survey KMAFRA Korean Ministry of Agriculture,. Administartion ROPS. Food, and Rural Affairs KOSHA Korea Occupational Safety. Rural Development. Rollover Protection Structures. RR. Rate Ratio. WCI. Workers’ Compensation. and Health Agency MOEL. Ministry Of Employment and. Insurance. Labor. 17.

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(21) 1. INTRODUCTION. Injury is a very important social agenda related to the social welfare system. Severe injury can cause death or disability, and has negative socioeconomic impacts on the injured, the family, and society [1,2]. Preventing and managing occupational injury in particular is an area for which the national social welfare system is accountable. The occurrence pattern of occupational injury differs according to occupation category and worker attributes. In addition to construction and mining, agriculture is considered a hazardous industry due to aging and diverse farm-work environments. In the US and some countries in Europe, farm-work related injuries have been studied and managed in a variety of ways for several decades. In South Korea, however, specialized research and management on farmers' occupational injury was not actively conducted until 2000s. Most farmers in South Korea are self-employed, not covered by the Occupational Safety and Health (OSH) Act, because the law is applied to businesses where employers and employees are distinguished. Therefore, most farmers are excluded from the national occupational safety and health system for occupational injury. Thus, to survey and investigate the scale and attributes of farm-work related injury nationwide, the Rural Development Administration (RDA) began to conduct the Korea Farmers’ Occupational Disease and Injury Survey (KFODIS) in 2008. With KFODIS, the scale of occupational injury in agriculture has been examined at the national level and the profile of injuries occurring in the country has been under investigation. MacKenzie (2000) argued that understanding the complex array of factors influencing injury occurrence is required to prevent injury [3]. Anderson et al. (2012) proposed that injury-causing factors can be analyzed with reference to safety systems based on the Hierarchy Of Controls (HOC), such as design and mitigation systems, arguing that more effective intervention programs for the prevention of occupational injury can be developed with this approach [4]. Recent studies have pointed out that farm-work related injury was influenced by a variety of risk factors, including gender, age, and occupation category, the same as occupational injuries occurring in other industries [5], and that the prevention of farm-work related injury was effective when 19.

(22) prevention programs including behavioral and technical interventions were used in combination [6-8]. However, the scale of farm-work related injury and the risk factors were studied only in a few areas in South Korea [9,10]. Although farmers' health and safety is a serious issue and the International Labor Organization (ILO) proposed recommendations for agricultural occupational safety and health in the early 2000s [11], for a long time, South Korea as well as US and European countries did not have an OSH act specialized for agriculture [9,12,13]. The Act on Farmers’ and Fishers’ Occupational Injury and Disease Insurance and Prevention was finally passed on National Assembly in 2016 as a result of experts' persistent effort. South Korea became the only country that legally addressed prevention of farm-workrelated injury and disease among Far Eastern Asian countries. Demands to develop intervention program, enforcement, regulations, and guidelines to prevent farm-work related injury have increased, following the enactment [14]. Accordingly, the aims of this thesis were to explore the scale and attributes of occupational injury in farmers in South Korea, investigate risk factors and root causes of farm-work related injury by utilizing the HOC-based safety systems, and suggest a direction for developing checklists and relevant regulations to use in future agricultural safety intervention programs.. 20.

(23) 2. REVIEW OF THE LITERATURE. 2.1 THE INTRODUCTION OF AGRICULTURE AND RURAL SOCIETY IN SOUTH KOREA 2.1.1 General characteristics of agriculture and rural society South Korea’s population was approximately 51.4 million in 2017, and the number of farmers and farms was 2,422,000 and 1,042,000, respectively [15]. The climate in South Korea was temperate with an average annual temperature of 10–15℃. The hottest month was August (23–26℃) and the coldest month is January (-6-3℃). Annual precipitation in the central region was 1200–1500 mm and 50–60% of it was concentrated during the summer months [16]. Major farm crops grown in flatlands include rice, barley, fruit and vegetables (tomatoes, cucumbers, etc.), dry field crops (cabbages, potatoes, sweet potatoes, etc.), and flowers (roses, chrysanthemum, etc.). In mountain areas, a variety of tree fruits including apples, pears, and persimmons are produced. Before 2000, most farming families grew rice, but beginning about 20 years ago, production of crops that can grow with high productivity in the small space of a greenhouse (such as cucumbers, tomatoes, and roses) has increased as a result of soaring land prices and advances in farming technology. The total agricultural area was 1,620,796 ha, with rice production consuming the largest area, followed by tree fruits and greenhouse products [17]. 2.1.2 The attributes and changes of agriculture Historically, South Korea was an agricultural country with rice as the primary crop, and farmers were considered top priority when national economic policy was established. However, with the sharp population increase and a decrease in food self-sufficiency following the Korean war, agricultural policies have been created and operated from the perspective of the food industry rather than from farmers' viewpoints [18]. Since the 1960's, varietal crop improvements and the introduction of agricultural machinery, greenhouses, and agricultural chemicals have enhanced productivity. A large majority of farms now use rotary tillers, tractors, combine harvesters, and other machinery. The utilization rate of agricultural machinery 21.

(24) in rice production has reached approximately 97%, thus increasing agricultural productivity [19]. However, it was difficult for small farms to purchase and use agricultural machinery in open fields and greenhouses; therefore, growing crops in those areas still have relied on farmers’ intense physical labor [20]. In the 2000's, South Korea signed Free Trade Agreements (FTA) with the US, China, and the ASEAN countries, among others [21]. Through these agreements, the South Korean agricultural market was opened in exchange for the exportation of manufactured goods. Agricultural products imported from Southeast Asian countries, China, and the US have been sold at much lower prices than domestic agricultural products, reducing the competitiveness of domestic products and causing great financial difficulty to farming families in South Korea. To cope with the deteriorating profitability of farming, farmers have recently employed an increasing number of migrant workers [20]. Migrant farm workers are largely classified as foreign-born individuals married to a farmer, migrant workers legally registered at an incorporated farm business for animal husbandry (e.g., a pig farm), and workers with a short-stay visa employed temporarily during busy farming season (e.g., during potato harvest season). Currently, accurate statistics on migrant farm workers are not available because of their temporary nature. 2.1.3 Structural change and aging in rural society and farming With the overall structural changes in South Korean society (e.g., accelerated industrialization and policies centering around increased farm productivity), rural societies in South Korea have also undergone structural changes. The population in rural societies has sharply decreased, with mass rural-to-urban migration resulting from the influence of rapid industrialization and economic development from the 1960's forward. In 1965, the farm household population was 55.1% of the country’s total population, but it sharply decreased to 10.8% by 1995, and the 2017 figure was as low as 4.7%. The rural-to-urban migration was concentrated around the young labor force in particular and as a consequence, the proportion of people age 60 or older increased rapidly in rural areas. The percentage of the rural population older than 65 was 7% in 1970 and 42.5% in 2017, showing that the rate of aging in rural areas more than quadrupled compared to urban areas [18,22]. Most aging farm families consisted of two members. Only older farmers tended to be left in rural areas, as young people left to seek jobs or an 22.

(25) education in urban areas [23]. Another trend was an increase of multicultural families, as male farmers who were past the prime age for marriage tended to marry women from Southeast or Central Asia [24]. It seems that such structural changes occurred rapidly because rural areas lacked public infrastructure such as welfare facilities compared to urban areas. South Korea's fiscal soundness was very poor following the Korean war and to improve the economy, the country adopted developmental strategies that focused on urban areas. As a result, public services in rural area has been out of focus [18,25]. Healthcare is a representative example of poor public services in rural societies. The number and quality of hospitals in rural areas are inferior compared to urban areas. The public health centers in rural areas managed by the government focus primarily on general healthcare, and do not handle occupational safety and health problems, which have been among the most important health issues to farmers [26]. In consideration of the rural aging trend, the potential for sustaining rural societies in the future is low unless the government takes action to improve management of occupational disease and injury in farmers, which constitute a large part in their health concerns [22].. 2.2 REVIEW OF OCCUPATIONAL INJURY IN AGRICULTURE RESEARCH 2.2.1 Occupational injury rates in agriculture Khanzode et al. (2012) defined injury as a lesion in the body resulting from an acute exposure to an external energy exceeding the threshold of physiological tolerance [27]. Chae et al. (2013) described farm-work related injury as physical injury that occurs from falling, being caught, or vehicle accidents while working with farming tools, machinery, or animals, or transporting to the farm workplace [10]. Farmers perform a wide array of faming tasks that include coping with environmental change such as changes in the weather, working with animals and plants, using agrochemicals, and driving agricultural machinery. Accordingly, agricultural injuries differed from occupational injuries associated with other industries [18,28]. Globally, agriculture has been recognized as a very hazardous industry in terms of occupational safety and. 23.

(26) health, and many studies have been conducted to examine the rates and attributes of agricultural injury and disease [5,29-32]. The characteristics of agriculture and rural societies are different for each country. Studies have, therefore, computed injury and disease rates using different methods, resulting in inconsistencies in the reported rates of farmwork related injury. A study that examined injury and disease rates in a cohort of farmers age 50 or older in Kentucky, US from 2002 through 2005 found that on an annual basis, 9.3 out of 100 had a farm-work related injury requiring hospital treatment [31]. Rautiainen and Reynolds (2002) stated that the US injury rate varies in the range of "0.6–16.6/100 per farmer" depending on the information source [33]. In Finland, an analysis conducted on 2000-2004 agricultural injury insurance records found that approximately 20.2% of 78,679 farmers were compensated for one or more injuries [34]. In a study conducted via telephone interview with 1,182 farmers in 2004 and 2005, approximately 16% reported at least one injury requiring hospital treatment in the past 1 year [35]. In Sweden, a 2004 study investigated farmers' injuries using mail and phone surveys and found that 4% of 5,062 farmers experienced farm-work related injuries [36]. Like the US, Finland, and Sweden, injury rates among farmers in South Korea have been computed using insurance records, surveys, and other methodologies. A survey study conducted with 8,064 farmers in 2008 reported that 3.2% had an injury that required resting without working, for four days or more in the past year [10]. The South Korean government reports annual rates of occupational injury and disease across all industries including agriculture on the basis of Workers' Compensation Insurance (WCI) records. In 2016, the rate of compensated occupational injury and disease cases was 0.49% across all industries, and the number specifically for agriculture was 729 out of 80,990 (0.90%). In 2012, the rate was 0.59% for all industries and 1.30% for agriculture alone. Thus, the rate of injury among agricultural employees continued to be about double the rate for all industries (Table 1) [37].. 24.

(27) 1,825,296. 1,977,057. 2,187,391. 2,367,186. 2,457,225. 2013. 2014. 2015. 2016. All industries. 2012. Year. 14,954. 12,350. 10,871. 8,841. 7,398. Agriculture. Number of workplaces. 18,431,716. 17,968,931. 17,062,308. 15,449,228. 15,548,423. All industries. 80,990. 68,697. 61,681. 50,634. 46,489. Agriculture. Number of employees. 90,656. 90,129. 90,909. 91,824. 92,256. 729. 647. 621. 638. 603. Agriculture. 0.49. 0.5. 0.53. 0.59. 0.59. All industries. 0.9. 0.94. 1.01. 1.26. 1.3. Agriculture. employees. employees. All industries. Proportion of injured. Number of injured. 25. Table 1. Number of workplaces, employees and injured employees by Workers' Compensation Insurance in South Korea from 2012 to 2016 in all industries and in agriculture..

(28) Although the agricultural environment and farmers' perceptions and attitudes regarding farm-work related injury differ across countries, and the definition of injury and data collection methods differ across studies, it is very clear that the scale of agricultural injury and the resultant loss of work ability are at a serious level [38]. 2.2.2 Type and source of farm-work injuries To understand the attributes of farm-work related injury, the source of injuries, the nature of injury causing events, and the types of injury should be examined. Sources of farm-work related injury include agricultural machinery, agrochemicals, rotating objects, moving objects, vehicles, blades, hilly farm roads, farm animals, and slippery or disorganized workplace floors. These sources of injury maximize hazards during a particular type of farming task, such as machinery repair, driving tractors on a road, harvesting, and shepherding farm animals. If safety systems to eliminate or mitigate the hazard are absent or faulty, a variety of farm-work related injuries can occur, such as being severed, caught, or crushed [39,40]. Globally, a considerable number of farm-work related injuries resulted from agricultural machinery [41-46]. In South Korea as well, studies have reported that agricultural machinery was the source of a large number of agricultural injuries [18]. Typical accidents involving agricultural machinery were traffic accidents related to suboptimal lighting and the machinery's slow speed when it was driven to a farm field, and machinery overturning on sloped land [47]. However, South Korea differs from other developed countries in that cheap rotary tillers distributed in the 1970s as part of a policy emphasizing agricultural productivity are still widely used. Thus, a considerable number of farm-work related injuries in South Korea resulted from rotary tillers that were difficult to operate and not equipped with safety belts and Roll-Over Protection Structures (ROPS) [18]. The most common types of farm-work related injuries are falls, slips, and trips [48]. Falls typically occur during barn roof maintenance, tree fruit harvest, etc. McCurdy and Carroll (2000) reported that a fourth of all farm-related injuries in the US were caused by falls [41]. According to Rautiainen et al. (2009), floors, walkways, obstacles, trailers, wagons, tractor steps, uneven terrain, slippery terrain, etc. were sources of falls/slips/trips [47].. 26.

(29) 2.2.3 Increase of occupational injury and disease in farmers and change in agricultural policy The agricultural policy that focuses on increased food production stimulated the innovation of agricultural technology, accelerating the production of farm crops per unit area. However, in exchange for improved productivity, farmers experience a variety of occupational injuries and diseases (such as musculoskeletal, respiratory disease, heat stroke and other conditions) stemming from new hazards related to agricultural machinery and chemicals and it proves that agriculture is still one of the top 3 hazardous occupation along with mining and construction [49, 50]. South Korea's agricultural structure is diversifying from rice farming to more profitable greenhouse farming and animal husbandry. With these changes, diverse types of occupational injury result from agricultural machinery, animal handling, hot, humid, confined, and small-spaced work environment, and other hazards. Moreover, farmers’ occupational injuries are not adequately prevented or managed because of the poor occupational safety and health services in rural areas mentioned above. Farmers’, stakeholders’, and government workers are also lack of understanding regarding the importance of occupational safety and health management. As a result, farmers are further burdened with personal, economic, and social difficulties [18]. Most aging farmers work past the typical retirement age in South Korea as well as in other countries, such as Sweden [36]. Aging and decades-long farming cause physical strength, reflexes, and immunity to weaken, and induce long-term exposure to hazards, further increasing the likelihood of occupational injury and disease. The demand of physical labor is still high in open-field farming (the second largest farm type in South Korea, following rice) because of the low rate of farm mechanization [20]. Liebman et al. (2013) showed that migrant farm workers were exposed to additional risk factors as a result of linguistic barriers, their status as a foreigner, and insufficient safety training [12]. Migrant workers who come to South Korea to replace aging farmers are in a similar situation. Accordingly, the South Korean government suggested a new agricultural policy for farmers suffering from farming debt, poor welfare conditions, etc. The government has attempted to move away from the existing policy focusing on agricultural technology development to increase farm household income and transition to policies that sustain rural societies by improving the welfare of rural areas. To concretize such policy, in 2003 the Korean Ministry of 27.

(30) Agriculture, Food, and Rural Affairs (KMAFRA) enacted a law to improve the welfare of farmers, suggesting, for the first time, a move toward a national policy on agricultural health and safety [50]. 2.2.4 Risk factors for farm-work injuries Risk factors refer to the exposure, attribute, or characteristic of an individual that increases the likelihood of injury or disease [5,51]. Research on farm-work related risk factors has been conducted using various methods in the US and the EU. The categories of risk factors reported to be associated with farm-work related injury included gender, age, farm type, drinking history, employer/employee status, work hours, sleep hours, and linguistic barriers [5,6,52]. The relationship between gender and farm-work related injury has been examined in many epidemiological studies. The Odds Ratio (OR) with their 95% Confidence Interval (CI) for men vs. women were reported to be 1.27 (95% CI: 1.06−1.51) [48], 1.75 (95 CI: 1.68−1.82) [34], and 1.77 (95% CI: 1.65−1.88) [44], showing that the risk for farm-work related injury is significantly higher in men than in women [5]. In a 2009 survey conducted with 8,064 farmers in South Korea, the rate of injury was 4.3% and 1.9% in men and women, respectively, showing a significantly higher rate of occupational injury in male farmers [10]. The findings regarding the association between age and farm-work related injury vary depending on the study population or the farming environment. In the US [6], the OR of farm-work related injury was higher for farmers in their 20's-30's than for those age 40 or older. A survey conducted with full-time farmers in Finland found that, unlike the US finding, the rate ratio (RR: 1.91, 95% CI: 1.01-4.00) was significantly higher for farmers in their 30's compared with those age 60 or older. A Swedish study did not find age differences in occupational injury rates [36], and a study conducted in South Korea found that the OR with farmers under age 50 as the reference was 1.53 (95% CI: 1.46-1.60) for farmers in their 50's, 1.45 (95% CI: 1.39-1.51) for farmers in their 60's, and 1.94 (95% CI: 1.86-2.02) for farmers over age 70 [10], suggesting that the rate of farm-work related injury increased as farmers' age. Different studies have reported varying results regarding the relationship between farm-work related injury and farmer status (i.e., employer or employee/family member). In a meta-analysis conducted across five studies, the pooled OR estimate for owner/operator was 1.64 (95% CI: 1.13−2.38), comparing to family members or hired workers [5]. 28.

(31) With respect to farm type, it has been shown that the incidence of occupational injury was higher in animal husbandry (such as pig farming and dairy farming) compared with crop farming [47]. Also, long work hours were reported to increase the incidence of occupational injury [35]. In farming, it frequently occurs that farmers work (sow, harvest, etc.) in a rush as a result of crop, livestock, and weather conditions. Studies have shown that working in a hurry was strongly associated with farm-work related injury [53,54]. During harvest season, farmers often work into the night to finish harvesting with limited manpower in a restricted period of time. Zhu et al. (2014) pointed out that farmers sleeping for 6 hours or less a night were 59% more likely to be injured than those getting 8-hours or more of sleep per night [55]. Drinking alcohol before work is also a risk factor for farm-work related injury [41,56]. The association between working under the influence of alcohol and injury has not been examined nationwide in South Korea. Over a 1-year period from April 2002, there were a total of 680 accidents involving agricultural machinery in North Gyeongsang Province of South Korea, and 25 (3.7%) among them were confirmed to have resulted from driving agricultural machinery under the influence of alcohol, suggesting that drinking is a risk factor for agricultural injury involving machinery [57]. The nationality of employed farm workers may also be closely linked with farm-work related injury. McCurdy and Carroll (2000) listed migrant worker's linguistic barrier as a risk factor for occupational injury [41]. Given that the numbers of migrant workers and multicultural families are an increasing trend in rural South Korea, the rate of occupational injury among migrant workers compared to all farm-work related injuries will likely increase.. 2.3 REVIEW OF OSH MANAGEMENT IN AGRICULTURE 2.3.1 OSH system in South Korea To reduce the high rate of occupational injury and disease in agriculture, the ILO recommends that each country establish OSH agriculture policies and develop national-level management systems and laws to support the policies. The type of the OSH policy applied to agriculture, the manner in which the law is applied, and who is covered by the law differs across countries according to the developmental history of agriculture/rural societies, OSH policy systems, the attributes of government organizations, the social welfare system level, and 29.

(32) the presence or absence of public institutions for social insurance for farmers, etc. Institutions that manage farmers' welfare do not exist in a large number of countries. Many countries do not have national OSH agriculture policies because self-employed farmers constitute a large majority of the agriculture industry [13,12,58]. Exceptions include Germany, Austria, and Finland, where social insurance has been established separately for farmers and OSH regulations in agriculture are enforced. In addition, farms with more than 10 workers are covered by federal OSH Act regulations in the US. However, farms with 10 or fewer workers, which includes 95% of all farms in the US, are exempt from the regulations. Most farmers are neither required to get farm safety inspections nor subjected to safety management requirements [59]. In the EU, there are no occupational safety and health laws or directives specific to self-employed farmers. However, agricultural safety and health regulations concerning particular hazards such as agricultural machinery are suggested via EU directives [40]. In Sweden, the systematic work environment management commonly applied to all industries is also applied to agriculture. In general, the work management criteria defined in the OSH Act are applied in agriculture, with the exception of such sources of injury as agricultural machinery and chemicals [13]. Similar to Sweden, farm owners are accountable for work environment management and injury prevention on the basis of the OSH Act in Finland. In addition, the Finnish government operates the Farmers' Occupational Health Services (FOHS) by utilizing financial incentives separately from the OHS Act to make it easier for farmers to take a lead in safety management [60]. In Asian countries, most of the laws and regulations on occupational safety and health are applied exclusively to manufacturing and mining industries. Reed et al (2013) stated that the OSH Act was rarely applied to dairy farmers in Asian countries, because dairy farms in those countries were mostly small-scale and self-employed businesses operated with family members [13]. Most countries do not have occupational safety and health laws, requirements, or regulations specific to agriculture that comprehensively include agriculture injury sources and risk factors, or that take into account the attributes of farming, rural society, and farmers. Also, the enforcement level of regulations on occupational safety and health vary greatly among countries according to the type and extent of social welfare service available to the country’s farmers [13]. 30.

(33) Farmers in South Korea are not covered by the existing national system for occupational safety and health, regardless of whether they are employers or employees. In 2016, of 2.4 million farm workers, only 3.3% had WCI coverage. It is very difficult to apply the existing city- and factory complex-centered management system for occupational safety and health to agriculture because farms are geographically isolated. Hence, the Ministry of Employment and Labor (MOEL) and Korea Occupational Safety and Health Agency (KOSHA) have been reluctant to apply the OSH Act to agriculture [18,37]. The South Korean system of occupational safety and health is operated by dividing the roles into three parts, government, employer, and employee. However, it is difficult to operate such divisive system with family farmers and self-employed farmers. Some of the farmers who are simultaneously an employer and employee take risks and intentionally avoid occupational safety and health management, for short-term economic gain. In this context, applying the existing system for occupational safety and health may induce farmers to resist [61]. Although farming may be considered as a single industry, a great variety of farm types and farming method exist. Accordingly, the manner and criteria of occupational safety and health management should be diverse. The regulations currently stated in the OSH Act, developed for the manufacturing sector, are very difficult to apply to such diverse farming environments [62]. As discussed above, South Korea began to perform research and intervention projects on occupational safety and health in agriculture for some farm types and farmers only in the 2000's and endorsed the ’ Act on Farmers’ and Fishers’ Occupational Injury and Disease Insurance and Prevention’ in 2016. Thus, the country is in the midst of initiating a nationwide integrated system for occupational safety and health in agriculture, as recommended by the ILO [63]. 2.3.2 3Es intervention programs (Education, Engineering and Enforcement) Identifying errors in safety systems developed to prevent occupational injury, and investigating the attributes, status, and risk factors of occupational injury, are prerequisites for developing criteria to effectively manage occupational safety and health. Haddon (1980) suggested that occupational injury is an outcome of the interplay among humans, causative agents, and external environments [64]. On the basis of that suggestion, many agricultural safety and health intervention projects have used approaches based on the three ”Es” 31.

(34) (i.e., Education, Enforcement, and Engineering control) to prevent farm-work related injury [65]. Angoules et al. (2007) argued that most agricultural injuries were preventable through high quality education, safety precautions, and the use of personal protective equipment (PPE) [42]. However, a systematic review that evaluated the effect of existing agricultural safety and health interventions on reducing the incidence of agricultural injury found a lack of significant effect for education-based interventions in decreasing injury incidence [7]. Previous studies argued that improving the work environment or safety systems by revising safety regulations was more effective than education in reducing the incidence of occupational injury [59,66]. Furthermore, Kaustell et al. (2011) reported that removing hazards was more effective compared to training workers to use PPE or follow safety procedures [67]. 2.3.3 Farm-work related injuries and safety systems McQuiston et al. (2012) said that most accidents and near-misses occur because of one or more root causes, that may be traced to the absence of, or error in, safety systems [68]. Safety systems can be categorized on the basis of efficiency and ease of implementation as follows: design/engineering, mitigation devices, maintenance and inspection, warning devices, training, procedures, and PPE. Root causes contributing to accidents and near-misses can be derived using a logic tree diagramming method and may be classified as safety system errors. Logic tree diagramming is an accident investigation method that graphically summarizes and describes the attributes of accidents by performing the necessary test, the sufficient test, and the stopping test and investigates the associations between accident causes and consequences. One disadvantage of the method is that the quality of results varies depending on the researcher and the participants, but it was reported to be effective in linking the root causes of accidents to safety system errors [68]. Safety systems in agriculture can be defined according to the classification of safety systems proposed by previous study [69]. Design/engineering and mitigation systems include the elimination, substitution, or blocking of a hazard, such as shields for rotating blades in machinery, shut down devices that protect farmers in an emergency situation, and substituting safe structures for hazardous ones [7].. 32.

(35) Maintenance/inspection means to inspect and maintain the safety status of infrastructure, machinery, facilities, and workplace through safety checks, evaluating farmers’ health, and measuring the hazard concentration in a specific workplace [70]. Examples of agricultural safety systems include farm workplace cleaning and maintenance, inspection/maintenance of agricultural machinery like tractors, and measuring gas concentration in animal waste composting areas. Warning/notification systems include alarm devices that activate in an emergency situation and warning boards to communicate the presence hazards [71]. The positive effect of warnings and safety signs on injury prevention has been demonstrated in many studies [71,72]. A representative example of a system used in farms includes safety stickers on agricultural machinery. Training/procedures include providing safety procedures, education, and training so that workers perform work safely [68,73]. This system is most commonly used in agricultural safety and health intervention, and has been reported to be effective in changing the perception, attitude, and behavior of farm workers [74]. However, substantial effects on reducing the incidence of injury and disease have not been clearly shown [7]. Human factor systems protect each worker individually from workplace hazards (e.g., wearing Personal Protective Equipment (PPE) [73]. In agriculture, PPE includes, among others, reflective work clothes, and safety shoes, glasses, and gloves. Similar to the classification of the safety systems in this thesis, the US National Institute for Occupational Safety and Health (NIOSH) defined methods for reducing exposure to occupational hazards as a Hierarchy Of Controls (HOCs), from the perspectives of feasibility and effectiveness. Similar to the aforementioned safety systems, HOCs are categorized into hazard elimination, substitution, engineering controls, administrative controls, and the use of PPE, from the top to the bottom of the hierarchy. The risk reduction efficiency of a method that was higher in the hierarchy is greater than that of a method lower in the hierarchy [75]. HOCs are an effective approach for managing industrial safety and health, but generally, they were not used in agriculture [65]. Identifying overlapping root causes of occupational injuries and improving error rates in relevant safety systems, including HOC implementation, was reported to be very effective in preventing occupational injury [68]. Hagel et al. (2015) found that risk was significantly reduced in farming families where four 33.

(36) of six modified HOC methods (hazard identification; risk assessment; personal protection; administrative controls; engineering controls; and hazard elimination) were used in combination, in comparison to farming families where those methods were not used (OR: 0.30, 95% CI: 0.11–0.83) [65]. MacKenzie (2000) suggested that analytical access to the complex array of injury attributes, outcomes, and factors helps develop ways to prevent injury [3]. .. 34.

(37) 3. AIMS OF THE STUDY. The purpose of the thesis was to explore level and affecting factors of occupational injuries of farmers and suggest way of development of checklist and regulation for agricultural health and safety. The specific aims were i.. to confirm the relationship between the incidence of injury and socioeconomic level in South Korea (Study I). ii.. to identify the magnitude of farm work–related injuries among farmers in South Korea and to evaluate the association between injury and risk factors (Study II). iii. to examine the root causes in injury cases and the identification of errors in systems of safety (Study III) iv. to review the items from various checklists using systems of safety and propose directions for improving checklists and regulations used in farm workplaces (Study IV). 35.

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(39) 4. SUBJECTS AND METHODS. 4.1. RELATIONSHIPS BETWEEN INJURIES AND TYPE OF OCCUPATION, INCLUDING AGRICULTURE. 4.1.1 Study sample: Korea National Health and Nutrition Examination Survey (KNHANES) participants The Korea National Health and Nutrition Examination (KNHANES) is a survey conducted by the Ministry of Health and Welfare (MOHW) to examine the health and nutritional status of South Koreans. The survey began in 1998 on the basis of Article 17 of the Statistics Act. Study I analyzed KNHANES IV data (the survey was conducted for 3 years from 2007 through 2009) [76]. Of 23,632 total participants, the data from 11,837 participants between ages 20 and 59 were analyzed using the KNHANES analysis guide [76]. Nearly 43% (n=5,047) of the study sample were male and 57.4% female (Table 2). The largest age group was 30 to 39 with n=3,470 (29.3%), followed by 40 to 49 (28.6%), 50 to 59 (24.4%), and 20 to 29 (17.7%). Regarding marital status, 18.1% (n=2,134) were never married and 76.5% had a spouse. Regarding occupation distribution, 5.5% (n=610) were skilled agricultural, forestry, and fishery workers. The largest occupation category was service and sales workers (17.1%), followed by managers, professionals, and administrators (16.4%), and clerks (10.7%).. 37.

(40) Table 2. Demographic characteristics of the subjects (n=11,837) in The Korea National Health and Nutrition Examination (KNHANES IV) survey. Variables. Categories. Frequency. Percent. Male. 5,047. 42.6. Female. 6,790. 57.4. 20-29. 2,097. 17.7. 30-39. 3,470. 29.3. 40-49. 3,386. 28.6. 50-59. 2,884. 24.4. Married. 9,018. 76.5. Bereaved. 244. 2.1. Divorced. 400. 3.4. Never married. 2,134. 18.1. Manager, professional, and administrators. 1,800. 16.4. Clerks. 1,179. 10.7. Services and sales worker. 1,886. 17.1. 610. 5.5. 1,413. 5.5. Elementary workers. 950. 8.6. Unemployeda. 3,163. 28.8. Gender. Age. Marital statusb. Occupationb. Skilled agricultural, forestry, and fishery worker Craft, Equipment, Machine operating, and assembling workers. a. including homemakers and students.. b. If the frequency does not add up to 11,837 within each variable, the remaining cases are unknown (=missing data). 4.1.2 KNHANES variables A KNHANES item asked about injury experience within the past one year from the survey date. Injury incidence was based on the response to this item. For demographic indicators, responses to the essential demographic questions, i.e., age, gender, marital status, and occupation, were analyzed. Occupation data 38.

(41) were collected using the occupation categories (a total of 7) proposed in the 6th Korean Standard Classification of Occupations (manager, professional, administrator; clerk; service and sales worker; skilled agricultural, forestry, and fishery worker; craft, equipment, machine operating, and assembling worker; elementary worker; and unemployed [77]. 4.1.3 Statistical methods The proportion of the injured out of the total study population was computed for each category of the following independent variables to examine the attributes of the injured: gender, age, marital status, and occupational category. To compute the adjusted OR and 95% CI of injuries for each occupation category, multiple logistic regression analysis was conducted by adjusting for gender, age, and marital status. All analyses were performed with SAS and the significance level was set at 0.05.. 4.2 FARM WORK–RELATED INJURIES AND RISK FACTORS IN KOREA (STUDY II) 4.2.1 Study sample: Korea Farmers’ Occupational Disease and Injury Survey (KFODIS) participants Since 2009, the Rural Development and Administration, South Korea has conducted KFODIS annually and reported the results as national statistics approved by Statistics Korea. The rural areas surveyed were determined based on number of farms, age distribution, and geographical attributes. Farms were sampled using a multistage stratified method based on the 2010 agriculture census results to ensure regional representativeness. In the 2013 KFODIS, 16,160 farmers age 19 or older were surveyed across 10,020 farms in 334 cities and counties. To enhance the quality of survey results, 100 field investigators were trained on survey methods, injury definitions, correct interpretation of each survey item, and the attributes of the survey sample. Field investigators visited the sampled farms, taking approximately 30 minutes with each farmer to complete the survey. Statistics professors worked with field investigators, staying with them in the survey areas to support and manage their work. The survey period was July 2 through July 18, 2013.. 39.

(42) Of the farmers, 52.6% were male and 47.4% female (Table 3). Eighty-three percent of the farmers grew rice (50%) or dry field crops (33%). The largest age group was 70-79 (n=5,566), followed by 60-69 (n=4,504), 50-59 (n=3,192), over 80 (n=1,627), and under 40 (n=1,271). Sixty-one percent were farm owners, and the most common length of farming experience was 40–59 years (45.8%). Ninety-five percent indicated that they worked on a farm for more than 6 months in 2012.. 40.

(43) Table 3. Demographic characteristics of the subjects in Korea Farmers’ Occupational Disease and Injury Survey (KFODIS) in 2013 (N=16,160). Variable Gender. Category. Frequencya. Percent. Male. 8,502 (7,905)b. 52.6. Female. 7,658 (1,921). 47.4. c. 1,271. 7.9. 50-59. 3,192. 19.8. 60-69. 4,504. 27.9. 70-79. 5,566. 34.4. ≥ 80. 1,627. 10.1. Owner. 9,826. 60.8. Non-owner. 6,334. 39.2. ≤ 19 years. 2,589. 16. 20-39 years. 3,681. 22.8. 40-59 years. 7,401. 45.8. ≥ 60. 2,489. 15.4. 1-2 months. 77. 0.5. 3-5 months. 734. 4.5. 6-8 months. 7,674. 47.5. More than 9 months. 7,652. 47.4. Rice. 8,088. 50. Dry field crop. 5,311. 32.9. Orchard. 1,368. 8.5. Greenhouse. 783. 4.8. Animal husbandry. 315. 1.9. Others. 295. 1.8. ≤ 49. Age. Farm ownership. Working years in agriculture. Working months during 2012. Type of farm. a. If the frequency does not add up to 16,160 within each variable, the remaining cases are unknown (= missing data).. b. Number of farm owners within each group.. c. 1.7% (282 farmers) were 39 years old or younger and 6.1% (989 farmers) were 40-49 years old.. 41.

(44) 4.2.2 KFODIS variables Of 41 KFODIS items, age, gender, farm ownership, number of years working in agriculture, number of months working in 2012, type of farm, nighttime work experience (at least once), and work experience under the influence of alcohol (at least once) were treated as potential risk factors for agricultural occupational injury in Study II. A farm-work related injury was identified when a respondent indicated that a work-related injury requiring outpatient treatment or hospital admission occurred in 2012. To minimize recall bias, farm-work related injuries (the dependent variable) included only those cases where the respondent visited or was admitted to a hospital. 4.2.3 Statistical methods Statistical analysis was performed using IBM SPSS Statistics OSX (version 22.0; IBM, Armonk, NY, USA). Seven respondents were excluded because of incomplete responses, and data from 16,153 were included in the analysis of farm-work related injury and risk factors. Chi-square tests were used to examine differences in the proportion of injured farmers in 2012 across different risk factor categories, and univariate logistic regression analysis was conducted to compute the OR for each risk factor category. Finally, to develop a model for the relationship between risk factors and injury, stepwise multivariate logistic regression analysis (forward selection) was performed using the following independent variables: gender, age, farm ownership, working years in agriculture, working months during 2012, type of farm, night work experience, and work experience under the influence of alcohol.. 4.3 FARM-WORK RELATED INJURIES AND ERRORS IN SAFETY SYSTEMS (STUDY III) 4.3.1 Sample: Injury claims records In Study III, farm-work related injuries were extracted from the injury insurance claim database of the Mutual Aid Insurance (MAI) of the Nation Agricultural Cooperation Federation (NACF) of South Korea using criteria listed below. MAI had been a monopolized private insurance for farmers’ work related injury and. 42.

(45) disease until 2015. In 2006. there were a total of 27,864 claims that received insurance compensation and of those, 227 injury cases were sampled. •. Injury causes included contact with machinery/facility/tool, slip/trip/fall, strangulation, contact with sharp materials, and collision with materials. •. Injury occurred after January 1, 2005. •. Injured person was born after 1950. •. The insurance payment was 300,000–500,000 Won (approximately 300– 500 USD), based on the type of injury. •. Sufficient data were available (e.g., telephone number and detailed description of injury). Telephone interviews were attempted with the farmers from the 227 injury cases, and 33% (n=75) participated in an interview. The telephone interviews collected the farmers’ personal information, the characteristics of the materials involved at the time of the injury (e.g., machinery/facilities/tools and use of safety equipment), and the farmers’ training/education experience, etc. The interview was completed for 68 cases, 60 of which were men. Most of the injuries (83.8%) occurred in farmers in their 40's or 50's (Table 4). Table 4. Distribution of gender and age of subjects for completed cases (n=68) of farm-work related injury telephone interviews in 2007. Variable. Category. Frequency. Percent. Male. 60. 88.2. Female. 8. 11.8. Below 40. 6. 8.8. 40 to 49. 25. 36.8. 50 to 59. 32. 47.1. 60 and above. 5. 7.4. GENDER. AGE. 43.

(46) 4.3.2 Identifying safety system errors A previous study suggested the logic tree diagramming method for identifying root causes of occupational injuries [69]. This method was used to extract root causes from each injury case. The Figure 1 is a example of analyses with the logic tree diagramming method.. Figure 1. Example of logic tree diagramming about low back injury by heavy workload. The root causes of injuries were categorized by associated safety systems for which we developed criteria. The definition of each system in this study, however, is a little different from that suggested in previous studies [68,69], as the farm workplace has different characteristics, such as working alone, the type of machinery involved, etc., compared to other industries. Some farmers were reluctant to recall the moment of their injury because doing so caused distress. Consequently, we failed to extract some of the root causes, which were classified as NMI (Need More Information). Root causes based on natural events such as weather conditions, snow, the weight of stone, and other unavoidable events in the natural environment, were defined as unpreventable errors.. 44.

(47) 4.4 ANALYSIS OF CHECKLISTS FOR AGRICULTURAL SAFETY MANAGEMENT (STUDY IV) 4.4.1 Checklist search In Study IV, the checklist attributes used to manage occupational safety and health in the farm workplace were analyzed based on the definition of safety systems. Generally, the checklists were public or downloadable from a webpage rather than from an academic database so that field workers and local professionals had easy access. To select which checklists to analyze in Study IV, the following key words and phrases were used to search the Internet via Google: agriculture, checklist, accident, disease, health, safety, farmers, farm workers, risks, hazards, and management. As of January 6, 2016, 54 checklists were retrieved and four of those were selected for analysis on the basis of safety system definitions (Table 5). These included: •. checklists developed by an international organization, national health and safety authority, or agricultural association in Western countries. •. checklists suitable for use on any type of farm, including self-employed and family farms. •. checklists written to be easily understood by farmers. 45.

(48) Table 5. Name, number of items and publisher/country of analysed checklists to manage occupational safety and health in the farm workplace. Checklist name. Number of items. Publisher/Country. Ergonomic checkpoints in agriculture. 100. ILO. Checklist for maintenance activities in agriculturea. 152. EU-OSHA. Risk assessment documentb. 113. HAS (Ireland). Risk assessment toolc. 172. National Resources Institute (Finland). a. This checklist is contained in “Maintenance in Agriculture - A Safety and Health Guide”. b. This checklist is contained in “Farm Safety Code of Practice” (Health and Safety. c. Original Finnish title of the checklist is Työ turvallisuusriskien hallinta, b-osa. (European Agency for Safety and Health at Work, 2011) Authority, Ireland, 2006 (Occupational safety risk management, part b) and the checklist was found through website of Natural Resources Institute, Finland and translated by Prof. Kimmo Räsänen of University of Eastern Finland, one of the authors. 4.4.2 Categorizing safety system items In this study, each of the checklist items was categorized using criteria based on safety systems and sub-systems (Table 6). Items not identified within the six safety systems were labeled as ‘Not Categorized’ (NC). Table 6. Definition of systems of safety and sub-systems for categorizing the items of checklists to manage occupational safety and health in the farm workplace. Systems of safety Design (Safety system eliminating or substituting hazard on farm). 46. -. Sub-systems Elimination or substitution of hazard Safety design of agricultural machinery, workplace, infrastructure, tool, storage material Existence of proper tools, machinery, infrastructure, facilities for safety Designation of safe place for vulnerable people Storage of hazardous materials away from workplace.

(49) Maintenance/Inspection (Safety system inspecting or maintaining safety status). Mitigation (Safety system reducing or minimizing exposure to hazard and injury). Warning/Notification (Safety system raising alarm or notifying work about hazard). Training/Procedures (Safety system making farmer act safely during work). Human factor (Safety system protecting each farmer individually from hazard on farm). NC (Not categorized by systems of safety). - Maintenance and inspection of infrastructure, machinery, facilities, safety devices, and workplace - Hazard assessment - Inspection of work ability - Shutdown devices or blocking of sources of hazards - Supporting or securing devices - Reduction of weight and electricity - Existence of ventilation system - Existence of seatbelt, guard, and safety rail - First aid preparedness - Existence of emergency facility or devices - Rollover protection - Existence of rest or safe areas away from hazards - Ergonomic design of workplace and materials, and devices - Enough spaces, sockets and others for safety - Existence of sign or board for notification and warning - Existence of easy-to-see visual display of control - Existence of communication system for emergency situations such as alarming device - Material Safety Data Sheets available in workplaces - Existence and observance of procedures for safe task - (stable posture, pre-startup review, wearing seatbelt, turning off engine, clear visibility, positioning of materials, use of proper tools, working slowly, and buddy system) - Retention of information related to safety - Training and education for safety and health - Work performed by certified personnel - Use of personal protective equipment (PPE), sunscreens, work clothes and others for personal safety -. Indefinite target (injury and hazard) or method Administrative action Environmental protection Outsourcing of hazardous work Public sanitation General health management Farmers' recognition of hazard in workplace Management of work and environment. 47.

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(51) 5. RESULTS. 5.1 RELATIONSHIPS BETWEEN INJURY AND TYPE OF OCCUPATION IN KOREA (STUDY I) In Study I, analysis of the KNHANES data showed that 6.7% (n=797) of individuals experienced at least one injury within the past year (Table 7). Injury incidence was significantly higher in men (8.4%) than in women (5.5%), and higher in the of 20-29 and 50-59 age groups (7.4%) than in other age groups. Injury incidence in skilled agricultural, forestry, and fishery workers was 7.7%, second to craft, equipment, machine operating, and assembly workers (10.6%). Injury incidence in the unemployed was 5.7%.. 49.

(52) Table 7. Injury proportion according to demographic characteristics of the subjects (n=797) in The Korea National Health and Nutrition Examination (KNHANES IV) survey. Variable. Category. Frequency. Proportion in each category. Male. 422. 8.4. Female. 375. 5.5. 20-29. 156. 7.4. 30-39. 215. 6.2. 40-49. 213. 6.2. 50-59. 213. 7.4. Married. 580. 6.4. Bereaved. 19. 7.8. Divorced. 42. 10.5. Never married. 156. 7.3. 47. 7.7. 108. 6. 79. 6.7. 114. 6.1. 150. 10.6. Elementary workers. 71. 7.5. Unemployeda. 194. 5.7. Gender. Age. Marital status. Skilled agricultural, forestry, and fishery worker Manager, professional, and administrators Clerks Occupation. Services and sales worker Craft, Equipment, Machine operating, and assembling workers. P-value of Chi-squared <.05. 0.1. <.05. <.05. a. including homemakers and students. b. If the frequency does not add up to 797 within each variable, the remaining cases are unknown (= missing data). 50.

(53) The multiple logistic regression analysis adjusting for age, gender, and marital status showed that the adjusted OR for skilled agricultural, forestry, and fishery workers was 1.43 using the unemployed as a reference. It was the second highest adjusted OR, following the adjusted OR for factory workers (1.99) (Table 8). Table 8. Odds ratios and 95% confidence intervals for type of occupation affecting the injury incidence rate by multiple logistic regression analysis.. a. Categories of occupation. Crude ORa. Unemployed. 1. Skilled agricultural, forestry, and fishery worker. 1.38. 1.01–1.91. 1.43. 1.02–2.01. Manager, professional, and administrators. 1.05. 0.83–1.34. 1.05. 0.83–1.33. Clerks. 1.19. 0.91–1.55. 1.18. 0.90–1.54. Services and sales worker. 1.07. 0.85–1.35. 1.08. 0.86–1.36. Craft, Equipment, Machine operating, and assembling workers. 1.96. 1.58–2.44. 1.99. 1.60–2.47. Elementary workers. 1.35. 1.02–1.78. 1.38. 1.04–1.82. 95% CIb. Adjusted ORc. 95% CI. 1. odds ratio. b. confidence interval. c. adjusted for age, sex, and marital status. 5.2 FARM-WORK INJURIES AND RISK FACTORS (STUDY II) In Study II, 580 (3.6%) of 16,153 farmers experienced farm-work related injuries requiring outpatient treatment or hospitalization at least once in 2012 (Table 9). The results of chi-square tests conducted on gender, age, farm ownership, the length of farming experience, and nighttime working experience showed 51.