This study used an ethnographic design during the summer of 2022 to explore the culture of Ohio farmworkers in relation to HRI and prevention. The P.I. worked in the field alongside farmworkers to have experiences similar to the group members and made observations to understand what was happening naturally. Semi-structured interviews were conducted following the observation phase with 10 farmworkers and four other potentially affected community members. Institutional Review Board approval was granted prior to the initiation of study procedures. Participants were compensated for participating in semi-structured interviews with a $20 Visa gift card. The P.I. conducted the interviews. This work was completed as part of dissertation research ¹⁸. We adhered to Standards for Reporting Qualitative Research (SRQR) guidelines (EQUATOR Network reporting guidelines)^19.

The first theme is Acquisition and Interpretation. Acquisition is defined as how one acquires knowledge, and interpretation is how one processes it. This theme encompasses the process by which farmworkers and other potentially affected community members acquire knowledge about HRI and prevention and how that knowledge is perceived and understood. This theme is represented by three subthemes: education and training, beliefs, and personal experience. They encompass farmworkers’ reports of learning and processing of HRI and prevention knowledge. These antecedents influence attitudes, subjective norms, and perceived behavioral control and are important to understand when developing an intervention targeted at change^20,21

The subtheme education and training encompassed workers and other potentially affected community members reporting what they know about HRI and prevention and their reports of where they gained this knowledge. For example, when asked what they have been taught about HRI, Javier (farmworker) responded, “Some people say don’t take too long on the sun”. Workers also reported not having education or training or being unsure of training or what they know. One worker reported that they had never been taught. Jose (farmworker) reported, “I ain’t never told ‘bout, just hearing there from my, you know, keep yourself hydrated pretty much.” While none of the workers reported specific instances of on-the-job training or education received from a supervisor, one potentially affected community member reported that orientation consisted of HRI training videos. Jason (human resource representative) reported, “that video would talk about types of clothing that are important, you know lighter colors that reflects on versus darker colors that absorb it” and “they do get into a little bit of the uhm telltale signs of heatstroke.”

While farmworkers and other potentially affected community members reported knowing about HRI, there were some misconceptions in their knowledge regarding sun safety and humidity. Eight workers appeared to confuse HRI with sun safety when asked what they knew about HRI. For example, sunscreen was reported as a method for preventing HRI. Marlin Man (farm owner) reported, “Well, with me, my heat-related illness has a lot of it has to do just with sun damage.” Three of these eight workers talked about skin cancer. Rosa (farmworker) reported, “it causes skin cancer.” Three workers expressed that humidity was protective against HRI. For example, Marlin Man (farm owner) stated that “I don’t think there’s as many heat-related issues in the humidity.”

The subtheme of personal experience consisted of participants’ reports of having a personal experience with HRI for themselves or others. Twelve of 14 (86%) participants in our study reported an experience with HRI that involved themselves or others. Seven out of the 12 who reported having a personal experience reported accounts of HRI and reported symptoms that were of the more serious forms, heat exhaustion and heat stroke. For example, Will (farmworker) stated, “I got dizzy and vomited.” Jose (farmworker) talked about his experience as an observer of HRI, “They just got real cold and cold sweats and turned pale.” Hector stated he “Just like got lightheaded. Felt real weak. I wasn’t sweating and kinda was getting more dizzy by the second” and reported “lying down in the back of like a semi-trailer in the shade that was like cooled off like the aluminum floor was cool.” Then stated he “went back to work. I felt a little bit better. I wouldn’t say I was like 100 percent, but I was good enough to go back out.” Raymond (farmworker) reported when he was 16, he “fainted before” and “my father had put me inside the tractor. With a tractor had A.C. [air conditioning], so you know I went in there to cool down and got better and started working again.” Participants also report on actions taken during an event of HRI. For example, Kristen (farmworker) reported that when her little brother had a heatstroke, they “put him in cold water to revive him.” During the P.I.’s time working on the farm, no incidents of HRI were witnessed or experienced by the P.I.

The subtheme beliefs encompasses participants’ interpretations surrounding HRI and symptoms. Beliefs can be influenced by factors such as knowledge, culture, or emotions. Many participants expressed beliefs and assumptions about HRI. Four participants’ responses showed that they understood that HRI is dangerous and can occur in a short amount of time. David (farmworker) stated, “Well, I know it-it’s scary.” Will (farmworker) stated, “I know it comes on quick. People ignore it.” However, some statements illustrate that participants had misconceptions about HRI. Will (farmworker) stated that “It’s bad when you stop sweating.”

Many beliefs appear to be rooted in truth. Will (farmworker) stated, “You should keep your shirt on, you know, guys that take it off, you know, that’s the worst thing you could do, you know, you want the water near your surface of your skin so it can evaporate to cool you down.” Jay (H.R. rep) said, “It’s probably a bigger issue than-than we even know.”

The second theme is Interoception. Interoception is still being defined and studied as a construct, predominantly in neuroscience and psychology²². Chen et al.’s²² definition fits closely with this theme: “Interoception includes the processes by which an organism senses, interprets, integrates, and regulates signals from within itself” ^{(p. 4)}. This theme is represented by three subthemes having to do with when participants sense or ignore cues for taking preventive measures such as resting or slowing down. These subthemes are listening to your body, the limit, and acclimatization.

The subtheme, listening to your body, encompasses participants’ subjective reports of body cues of how they felt, which let them know when to use preventions like breaks or drinking water. These included general statements of feelings, such as David’s (farmworker) statement, “If it got too hot, you know, go to the shade.” Raymond (farmworker) reported, “You just start adapting to what you need to do in order to feel some type of way.” Jason reported, “Yeah, I think the natural uhm instinct of self-preservation is to get yourself out of that situation.” Some participants had more specific reports of bodily cues. David (farmworker) reported, “I’ve had to stop during the day and take a break, because the uh-uh yeah, feeling overheated, or not being able to cool down my body fast enough.”

The subtheme, the limit, encompasses participants’ reports of going beyond what their bodies could physically endure regarding HRI. Emma (farm owner) reported that she’s had “experiences where I’ve kind of overdone it, you know, and I get dizzy if I try to like stand up too quickly or things like that.”

The sub-theme, acclimatization, encompasses participants’ reports on how they built their tolerance to working in the heat and their knowledge of acclimatization. There are recommended guidelines for acclimatization⁴; however, acclimatization in this analysis is represented by participants’ responses of articulating more towards instincts, “feelings”, and physical senses rather than a guideline or parameters for building a tolerance to working in the heat. Five participants had reports of just getting used to it. For example, Will (farmworker) reported, “You just go with it.” Similarly, Rosa (farmworker) said, “you just get used to it.” While others hold preconceived notions that themselves or others are somehow insusceptible. For example, José (farmworker) reported he is “immune.” Javier (farmworker) reported that “my family, we all, used to working on da, on hot weather.” Jay (farm owner) reported, “So you get used to it, but never really a formal protocol for doing that.”

The third theme is Perception. Perception is the way in which a person understands or interprets something. This theme is represented by several sub-themes: attitudes towards prevention measures, work norms, and control. Attitude towards a behavior is the extent to which an individual holds a positive or negative assessment of the behavior in question and is formed from behavioral beliefs²⁰. An example of this is the attitude that “it’s good to work hard” comes from the belief that a strong work ethic is a valuable trait. Subjective norm is a social factor influenced by a person’s perceived social pressure about performing the behavior²⁰. Control beliefs inform perceived behavioral control and are based on factors that increase or reduce the perceived difficulty of performing the behavior²⁰ Individuals’ perceived control over a behavior increases in relation to their belief in the ability to perform it related to factors such as access to resources and opportunities and it decreases in relation to the anticipation of obstacles or impediments²⁰. For example, if someone believes their concerns at work will not be listened to and taken seriously, then they may feel they don’t have the ability to change negative situations at work.

The subtheme, attitudes towards prevention measures, encompasses participants’ evaluations of HRI prevention measures that are either negative or positive. For example, Will (farmworker) stated, “I see people driving around and like they go to the air-conditioned car to the airconditioned wherever they’re going out, and then they go to the air-conditioned house. Oh, it’s so hot out. Like, how do you know you were never outside, you know?” He then added, “No, they’re just wimps.” Marlin Man (farm owner) expressed negative attitudes towards water stating, “I see people all the time, carrying around water bottles all the time. Sometimes I wonder if this isn’t a little exaggerated.”

The sub-theme work norms encompass participant reports of what they see as normal in regard to work and prevention. Hector (farmworker) reported that, “Everybody usually wears like the sun hat of different forms, whether it’s like a straw or the thing that protects your neck. Um, long sleeves, everybody kind of typically follows suit. Once you see one guy doing it, everybody else starts doing it.” Rosa stated, “That’s all you see out there. Everybody with long sleeves and big hats.” While working on the farm, the P.I. observed that most workers wore long sleeves, hats, and long pants. Many times workers were observed wearing hot dark colored material. For example, one worker was observed on several occasions picking produce in the field wearing a black long-sleeved sweatshirt with a hood on their head.

The subtheme of control encompasses participants’ descriptions of times when they report having control or having no control regarding using HRI prevention measures. This includes beliefs about the circumstances and other factors that they feel enable, reduce, or prevent their ability to use HRI prevention measures. Some reports from participants include feelings of control. Will (farmworker) stated, “They have water here, and you can get it any time” and “I can stop working any time.” Beam (farmworker) reported, “I’m not under a lot of pressure; if I, if I’m where I’m hot, I just go break.” Other times participants report having no control. Javier (farmworker) stated, “You gotta work whenever they tell you, you gotta work.” Raymond (farmworker) reported that “a bad boss or something like that” could keep people from using preventative measures and further explained that a bad boss was “Somebody that wants you to work, you know, get the, you get the-the job done. Uh it doesn’t matter how long it takes, it’s get it done, no break or nothing, they, ‘cause they’re greedy.” The P.I. observed that workers worked on their own time at the farm, and no one appeared rushed; however, there was not a set schedule, and the crops and the weather often dictated duties. For example, workers were pulled from normal duties, such as working in the market or mowing, to help pick corn as it was needed that day. In June 2022, a heat wave caused unseasonably warm temperatures and near-record highs. This heat wave was seen across the Ohio and Tennessee Valley from June 12–16, with temperatures recorded between 92–95°F and heat index values up to 120°F²³. Weather data for the area near the farm reported the hottest day was 95°F with an average high of 84.6°F²⁴. The P.I. observed the farm owner send several outdoor workers home early due to the heat. Workers were observed coming and going on the farm at their own schedules.

Farmworkers and other potentially affected community members discussed the actions they took to prevent HRI. This fourth theme, Action, was represented by several subthemes related to the prevention measures they take and recommend that others take to prevent HRI. The subthemes included personal protective equipment (PPE), shade, breaks, decrease body temperature, hydration, anti-prevention, and lifestyle behaviors and home remedies.

PPE encompasses participants’ reports of using PPE to prevent HRI. PPE included the use of clothing, hats, and sunscreen. David (farmworker) stated, “I wear a hat, uh, quite often.” Hector reported, “Really wearing like light colors, long sleeves to keep sun off.” The P.I. observed workers wearing long sleeves; however, they were not always wearing light-colored clothing, and on many occasions, workers were seen wearing black and other dark colors. The P.I. observed the frequent use of hats, and all the outdoor workers wore hats daily, including the P.I.

Shade encompasses participants’ reports of using shade to prevent HRI. Will (farmworker) reported, “Try to be in the shade as much as you can.” Jason (H.R. rep) also reported providing shade, “We provide them with a company van so that that provides, you know, shade and they can sit and take their breaks there.” Problems with a lack of shade were reported. For example, Emma (farm owner) stated, “Unfortunately, the fields don’t have like much shade directly in them.” The P.I. witnessed farmworkers’ use of a company van to transport themselves around the farm, and it was always parked within a few feet of where workers were picking.

Breaks encompass participants’ reports of using breaks to prevent HRI. Javier (farmworker) reported, “We’ll take a half an hour.” David (farmworker) reported, “They take a break at 10 [am] and of course, then have lunch and then take another break around 3 [pm] or so.” The P.I. witnessed workers taking breaks as they needed and did not witness reporting it to the farm owner. The P.I. did witness a worker leaving early due to the heat after reporting this to the farm owners. On the first day, the farm owner reported to the P.I. that they could take a break whenever they needed. The building where workers are offered breaks is in the market and air-conditioned.

Decrease body temperature encompasses participants’ reports of decreasing their body temperature or “cooling off” to prevent HRI. Participants’ quotes include the various ways they accomplished cooling off. For example, Jose (farmworker) reported the use of “a vehicle or something that has some type of A.C.” Rosa stated, “You sweat, it makes you cool.”. The P.I. also witnessed workers sitting inside of air-conditioned vehicles as well as going into the air-conditioned building for a break.

Hydration encompasses participants’ reports of using hydration to prevent HRI. Javier stated to prevent HRI, “Drink a lot of water.” The P.I. kept an insulated water bottle with her while working on the farm. On several occasions, the P.I. forgot her water bottle, but bottled water was available in refrigerators for workers. The P.I. only noted other workers drinking water on two separate occasions, but because workers are often working in separate areas, this was difficult to observe.

Anti-prevention encompasses participants’ reports of beliefs and actions surrounding HRI and HRI prevention that are false, according to experts. One participant reported the use of beer to help prevent HRI. Javier (farmworker) stated that “it [beer] helps to relax and give you more energy”. Will (farmworker) discussed things you shouldn’t do if you want to prevent HRI which he called “Anti-prevention,” and he explained that “Drinking coffee, alcohol, you know, those are both going to do the opposite effect.” The P.I. did not observe any alcohol use; however, early morning coffee consumption was observed.

Lifestyle behaviors and home remedies encompass participants’ reports of measures they took to prevent HRI that fall outside of the normal recommendations and things they do in their everyday life. For example, Will (farmworker) reported the use of “magnesium spray” for his leg cramps.

Several limitations exist for this study. Interviews were semi-structured; therefore, participants were not asked the exact questions in the same order. At times, participants did not elaborate on certain topics or constructs; however, the P.I. did not probe deeply to prevent a Hawthorne effect. This study consisted of a small number of participants, most of whom came from the same small family farm and may not be generalizable to all farmworkers in Ohio. Flyers were used to attempt to gain access to workers from various locations. Farmworkers are historically difficult to access⁸. One farm, where an interview with an H.R. rep occurred, stated they would allow workers to be interviewed but stopped responding to emails. Recruitment also consisted of emails and phone calls to other farms, but they either did not respond or denied access to workers and declined to give interviews. Several attempts were made to clinics that care for farmworkers and migrant workers to better understand healthcare professionals’ knowledge, beliefs, and attitudes toward HRI, but no responses were received. Another limitation was the potential for a lack of full and honest disclosure due to fear of repercussions for discussing work issues. To minimize this risk, participants were asked to choose pseudonyms, which were used instead of real names on the transcripts. The farm owners were not told who participated in the interviews or provided any details about individual responses by participants.