Index

Corresponding Author:
Dr. Dee Jepsen, Department of Food, Agricultural, and Biological Engineering, The Ohio State University, 590 Woody Hayes Drive, Columbus, Ohio, 43210. Email: jepsen.4@osu.edu.

Suggested citation: Beaudreault A; Jepsen D; Dellinger W. Designing an Agricultural Safety Intervention Program for Ohio Amish Youth. Cases in Public Health Communication & Marketing. 2009; 3:38-58.
Available from: www.casesjournal.org/volume3.

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Abstract

While the Amish population continues to grow because of the faith's high retention rate, the culture is underserved by many large-scale public health campaigns. Their choice of separation from public education and technology make it difficult, if not impossible, to reach them through traditional mass communication channels. This poses a challenge when designing safety education for Amish communities. Amish youth are exposed to home, farm, and occupational hazards at early ages; work is viewed as a privilege and an obligation to the family, community, and faith. The objectives of this outreach project were to identify, develop, and implement a safety program targeting Amish youth in order to mitigate the rural, agricultural, and occupational hazards to which they often are exposed. The overall success of implementing the program was based on social marketing that addressed the unique culture and the specific safety hazards that Amish children face daily. Through state collaborations and sponsored funding, a safety day camp model was introduced in two Ohio regions. Before program implementation, open-ended exploratory approaches were taken to identify common hazards faced by Amish youth. Focus groups with Amish leaders and parents allowed for deeper inquiry of youth safety practices. Questionnaires distributed to Amish youth (n=217) and parents (n=38) confirmed similar findings about youth exposures to agricultural hazards. A curriculum was developed, implemented, and evaluated in the pilot counties. Programmers were able to effectively target an underserved population with appropriate safety messages. Furthermore, the Amish population perceived the program as relevant and important for their youth.

Introduction

The Amish are a subset of the Anabaptist faith, a broad category that defines Christians of the reformation in Europe during the 1500s. Other Anabaptist faiths include the Mennonite and Hutterite populations. The Amish are typically distinguished from non-Amish Americans by their simple way of life, represented by plain dress and resistance to using modern technologies. ¹

In the United States, approximately 380 Amish settlements are located in approximately half of the 50 states. The Amish reside as far South as Florida and as far West as Montana. Two of the three largest U.S. settlements of Amish reside in Ohio, spreading over the Holmes/Wayne County region and adjacent counties. ²

As a subculture, the Amish population continues to grow. Amish family size averages approximately seven children, with a retention rate of 88% in the Anabaptist faith. ³ Despite this growth, the group is underserved in many large-scale public health campaigns. Amish beliefs that separate them from public education and modern technology pose challenges when designing safety education programs for Amish communities, in particular, youth safety messages. Amish youth are exposed to home, farm, and occupational hazards at early ages; work is viewed as a privilege and an obligation to their families, communities, and faith. The article presents a case study of a youth safety outreach project. The outreach project's objectives included identifying, developing, and implementing a safety program targeting Amish youth to reduce their exposure to rural, agricultural, and occupational hazards.

The outreach program was developed using a social marketing framework. With the theoretical model, authors attempted to address unique Amish culture and specific safety hazards the Amish children encounter. The guiding plan of action for the social marketing program was anchored to formative evaluation. This approach applied new information gained through the informal process evaluations. The "4 Ps" of social marketing-Place, Price, Product, and Promotion-guided the outreach program.

Background

Rationale for the Agricultural Safety Intervention
Agriculture is the number one industry in Ohio. The state ranks 13th in the nation in net farm income and is 35th in size. ⁴ The agricultural industry employs one in every six Ohioans, primarily in the areas of agricultural production, processing/packaging, distribution, and sales. Because Ohio relies upon the agricultural industry, agricultural safety is a priority among many populations.

The majority of Amish families do not claim production agriculture, i.e. farming, as their primary income. However, as rural and self-sustaining communities, their lifestyle may involve using practices conventional to non-Amish farming operations. Most Amish families generate their own produce and meat, along with the feed sources needed to sustain livestock. The Amish community's dependence on primitive farming methods, such as horse-drawn equipment and physical labor, increases their exposure to agricultural accident risks. ⁵

National studies suggest the farm as a dangerous setting for American youth. Approximately 124 youth are killed and another 23,000 are seriously disabled each year on American farms. ⁶ For youth under age 20, the average annual agricultural death rate was 155 deaths per year in 2001. ⁷ The same report concluded that approximately two-thirds of all farm deaths occurred to individuals younger than age 15. The leading injury-causing agents in both publications cited were attributed to machinery, water, and animals. ^8,9

The leading childhood health problem in the United States is injury. ^10-14Injuries account for more than 50% of all deaths among children, age 14 or younger. ¹⁵ However, injuries account for 80% of deaths among adolescents ages 15-19. ¹⁶ For every injury resulting in a fatality, an estimated 34 children are admitted to a hospital. ¹⁷

While data exists for American youth's farm-related injuries, published research of Amish agricultural-related injuries is limited. ¹⁸ The lack of research may be associated with the Amish lifestyle. The Amish do not commonly participate in health insurance programs and are unaccustomed to U.S. government programs.

Although limited, a few studies have been published that analyze farm-related injuries of Amish youth. Contributing factors to injury among children of the Old-Order Amish (a sub-sect of the Amish population) include: falls (either from haylofts or other equipment), animals, chemicals, or being crushed by equipment. ¹⁹ Pennsylvania Amish children's farm-related injuries over a period of 5 months resulted in 89 injuries and 5 fatalities of children, ages 3 months to 21 years. The average age of injury was 8.4 years. ²⁰

In a 9-state regional study, approximately 58 Amish children age 15 and younger were fatally injured from being run-over or crushed by equipment, animal-related injury, and falls. ²¹ The study reported a higher percentage of youth fatalities among the Old-Order Amish compared to the general farming population. The three most common injuries were falls, buggy crashes, and animal-related injuries. ²² Within the injury classification of falls, 49% resulted from falls through barn loft or hayloft holes.

The authors identified a need for education in the area of agricultural risk identification and injury prevention. The team also recognized that programs need to be suited to the specialized population, especially to Amish youth who encounter unique hazards in their home and farm environment.

Current Amish Safety Programming
Safety and personal health are valued among Amish populations. In Ohio, the Amish communities in the Holmes/Wayne County region have organized summer health fairs called, "Health and Safety Days." The health fairs are approximately two to four hours long, depending upon daylight and type of facility where the event is being held. The fairs are often conducted at livestock auction barns, fire houses, lumberyards, or private farms.

Public health and safety educators discovered the health fairs and asked the Amish planning committee if they could offer assistance. Local agencies that the Amish communities trusted were invited to collaborate. The agencies included local health departments, hospital outreach programs, fire departments, local law enforcement, natural resource personnel, e.g. the game warden, and Ohio State University Extension (OSUE) county office staff. The events have grown in recognition through the past 10 years, with attendance recorded at 2,000 Amish and Mennonite participants in 2007.

The Wayne/Holmes County Health and Safety Days have been adopted by other Ohio counties; including, Geauga, Logan, Knox, Morrow, and Ashtabula Counties, and involving similar public agencies. Typically, entire local Amish community attends the health fairs.

Topics at the health fairs are primarily adult-focused. Each year, the Amish Health and Safety Day Planning Committees identify topics important for the community. The topics may include road and buggy safety, water safety, fire safety, and hunting safety. Event coordinators began offering bicycle safety to the Amish youth as a result of promotional efforts through the health department and other local organizations. While bicycle safety is important, it was the only "youth-friendly topic" implemented. The absence of safety curriculum for children was a recognized limitation of the existing programming.

"Safety Day Camps" for Non-Amish Youth
Beginning in the 1990s, farm safety educators and several organizations initiated farm "safety day camps" in an attempt to attenuate injuries and fatalities in rural U.S. youth populations. These popular one-day camps are based in rural communities where the children live, and employ local resources for planning, teaching, and financial support. The camps vary in format and educational topics, and attendance ranges from 50 to 500 youth at each event. The mission is to educate youth about rural and agricultural safety through a hands-on, interactive approach. Studies suggest the model has been effective. ²³ OSUE has offered safety day camp programs for youth audiences since 1997. Throughout the past 10 years, more than 15,000 youth have attended 79 agricultural safety day camps in 30 of 88 counties in Ohio. ²⁴

Methods

Because of the longevity and success of the agricultural safety day camp program in Ohio, the "Agricultural Safety and Health Program" at The Ohio State University (OSU) received funding from the United States Department of Agriculture's (USDA) Cooperative State Research, Education, and Extension Service ²⁵ to culturally adapt and implement the day camp model for Ohio's Amish communities. This three-year outreach project utilized a basic social science research approach to revise the day camp model for Amish youth. Before programming was initiated, key stakeholders in the community were identified, including Amish Safety Committee members, to test the feasibility of an agricultural safety day camp for Amish youth. See Figure 1 (next page) for a map of Ohio that displays targeted counties for Amish safety day camps, additional potential counties to target, and counties with "traditional" non-Amish day camps.

Research Design of the Intervention Project
The intervention's overall aims were to explore and understand the Amish population's perceptions of potential youth exposures to certain rural hazards and to identify their views of education on these identified hazards. The project also explored the feasibility of a safety day camp model as an acceptable teaching format for Amish youth. Specific objectives of the outreach project included:

Objective 1: Identify stakeholders and develop partnerships to create an Amish youth safety program.

Objective 2: Develop safety curricula for Amish youth who live and work in rural areas.

Objective 3: Implement and evaluate the day camp concept as a viable methodology for creating awareness and teaching agricultural safety and health topics to Amish youth.

A qualitative research approach was used to explore the Amish leaders' attitudes towards youth safety. Qualitative research methods are oriented towards exploration, discovery, and inductive logic. Authors applied inductive reasoning to identify and code thematic patterns in data collection. Dimensions for analysis emerged from open-ended data collected by the researchers.

Focus group discussions and orally administered questionnaires were conducted. Focus groups were facilitated in two Amish communities in Ohio with adult members of the community (n=5; n=7). Recognizing the Amish as a patriarchal society, researchers invited only Amish men to the focus group discussions. They helped program staff identify key safety topics of importance for their community's youth. These same participants were members of the Amish Safety Committee or Amish Health and Safety Day Planning Committee, and agreed to include the intervention-the Amish youth safety day camp model-into upcoming events.

Each focus group began in the same manner. After introductions, the research team presented a short, seven-minute presentation, with color photo flipcharts that described the farm safety day camp model and how the program is implemented in traditional agricultural communities. Because this was a new educational method for the male participants in attendance, extended time was allotted to answer their questions. Following the presentation, a six-item discussion guide was utilized to direct the structured inquiry. Appendix A includes the focus group discussion guide.

Utilizing inductive reasoning, the researchers applied focus group discussion safety themes to develop two questionnaires. The questionnaires were administered to male and female Amish youth (n=217) and adults (n=38) attending the Holmes and Geauga Counties' Health and Safety Day events (n=3) throughout 2006-2007. The questionnaire was administered to persons visiting a safety exhibit. It provided an opportunity to validate the safety topics that emerged as important in the focus group discussions with a diverse convenience sample in the Amish community. Approximately 2,600 Amish family members attended the health fairs.

Due to participants' language differences and low-literacy rates in English, program staff had difficulty administering written questionnaires as originally designed. Amish children do not read English until they enter kindergarten, and then only a few have a good understanding of the written language until their adolescent years. Survey participants were asked to rank the safety topics on scale of importance; yet, the structure of the questionnaire was unfamiliar to Amish audiences who do not often participate in survey activities. Because of these barriers, study protocol was modified and the questionnaires were administered in-person and verbally to all youth participants and more than half of the adult participants. Because this project sought information from both Amish adult and youth audiences, OSU's Institutional Review Board (IRB) required submission of the focus group discussion guide and questionnaires prior to data collection activities.

Results

Focus group results were summarized into two broad themes: 1) the need for safety education for Amish children, and 2) the venues most conducive for facilitating educational sessions.

In both focus group sessions, participants agreed that the current Health and Safety Day format lacked age-appropriate safety sessions targeting youth audiences. Because many families attend these events, the focus group results suggest that additional programming, specifically for youth, would benefit Amish families. Holmes County's focus group identified an additional opportunity for the day camp format: incorporating the program into their established, "Farm Family Field Day" event. The event focuses on agricultural production, rather than public health initiatives.

The first question in the focus group was about channels in which youth receive or are exposed to safety education. This discussion led into specific ages and the type of work youth perform at those ages. Results identified common hazards youth were exposed to in their daily interactions. Participant responses to the last question, which asked participants to identify safety topics to include in the program, took approximately 45 minutes to one hour to complete.

Participants' responses were aggregated by subject and topic and are reported in Figure 2 (next page), with no weight given to any specific topic or level of discussion generated. Among the two focus groups, only slight differences emerged in discussion. For example, Geauga County Amish do not ride bicycles, but use rollerblades or roller-skates.

Regarding the questionnaire, Amish youth were asked to quantify the amount of exposure they had with the injury agents presented (Figure 3, next page). Similarly, parents were asked to rate their children's exposure to these same injury agents (Figure 4, next page). Comparable results were found between the Amish youth and Amish parent datasets. The majority of Amish youth (ages 5-13) reported that they rode bicycles (79%), or had contact with horses (71%) and livestock (52%) three or more days a week. Parents reported their children were exposed to horses (78%) and livestock (52%) three or more days a week. Seventy-five percent of the Amish youth reported they had exposure to lawn mowers approximately one to two days per week; compared with 68% parents reported their children had exposure to lawn mowers. However, in contrast to majority of youth (64%) who reported not using woodworking tools (0 days per week) and 39% of youth who reported not using hand tools (0 days per week), 57% of parents reported youth had contact with hand tools and woodworking tools approximately one to two days a week.

Additionally, parents were asked to identify the importance of safety training for 21 topics (Table 1). Fifty percent or more of the parents listed the following areas as "important" training topics for Amish youth: horses and horse-drawn equipment, ponds and water, hand tools, chemicals, rollerblades/skates, poisonous plants, tractors, livestock, electricity, woodworking tools, skid loader, stored feed, and severe weather. Interestingly, Amish parents do not think safety programming is needed for all-terrain vehicles and bicycles.

Program Outcome

Utilizing the information obtained through the two focus groups and survey research, researchers were able to identify relevant topics for education. The focus groups discussions also determined that the pilot counties were interested in a youth-focused safety program that modeled the non-Amish traditional agricultural day camp model. As key informants within the Amish community, the focus group participants were also valuable stakeholders in organizing the first day camp sessions. Their connection to the community enabled the program staff to plan, teach, and evaluate the effectiveness of the outreach initiative. Without the Amish leaders, buy-in from the target audience to participate in the day camps would have been difficult to obtain.

Four day camp programs were facilitated for Amish youth audiences; two in Geauga County and two in Holmes County during summer months of 2006-2007. An estimated 575 Amish youth participated in the safety education programs as part of their families' attendance at larger health and safety events.

These programs were well-received by youth participants, based on the authors' observation of the youth's interest and participation in the hands-on safety sessions. Young children attended the events with their parents, and adolescents traveling with their peer- groups participated in the safety education curricula. Participants explored the exhibits relevant to their lifestyles. The older youth replicated the teaching activities to younger family members in their German dialect. Program staff interpreted this repetition as a means of stressing the importance of the messages.

Program evaluations were developed specifically for youth in a low-literacy format to be completed following their day camp experience. Researchers intended for the youth to utilize a five-point Likert scale of varying degrees of "happy faces," and anonymously evaluate each session topic. However, during the first camp session, when Amish parents were asked to sign a permission form according to Human Subjects Review Standards, they were skeptical of the complexity of the language within the form and forbade their children to be part of what they perceived as a scientific research study. OSUE program staff did not want to compromise the trust they had developed with the Amish communities, and they decided to forego the opportunity to formally evaluate the educational program.

Discussion

The core of social marketing is to focus on the audience and voluntary behavior change. Such changes are for the benefit of the individual, group, or population. The benefit to the Amish in this social marketing program was the improved health of the entire community through individual behavior change. The inclusion of social marketing concepts led to the successful implementation of project goals.

An invitation to OSUE educators from the Amish Health and Safety Day Planning Committee to be involved in the day camp programs the next year was further evidence of success. The Amish communities have experienced two successful years of targeted youth safety programming and a third year is in planning stages. In addition to the day camp format, the educators were invited to present the safety lessons in an Amish school. The invitation was an honor because non-Amish educators are rarely invited into private Amish school settings.

Target Audience
The outreach intervention project's target audience was two Amish communities that acknowledged the need for health and safety events for youth. The primary intervention focused on Amish youth to increase their awareness of agricultural safety practices and when to apply those practices. However, the project could not be implemented until another key audience was targeted—the Amish Health and Safety Day Planning Committee. Influence and education from outside public health educators is typically forbidden, especially when the Amish children are the target audience. However, when key Amish adults and leaders have a role in identifying, implementing, and evaluating the safety programs, positive outcomes may be achieved.

Place
The safety day camps occurred in the Amish communities in locations selected by the Amish Health and Safety Day Planning Committees. The locations varied between the communities and were selected based on their ability to provide adequate space, lighting, and restrooms; also important was for the locations to have adequate space for buggy transportation and a stable area for horses. Locations of the day camps included a local lumberyard, livestock auction barn, firehouse, and family farm.

Price
Safety day camp programs were free for participants. For each event, Amish youth traveled to the safety events with their parents. Meals were provided by a community organization, usually requiring a donation. Effort was required for Amish participants who traveled by horse and buggy, and events were held during weekday evenings or on Saturdays to not take away from work obligations.

Product
The product of the outreach project was the day camp program itself. The Amish Health and Safety Planning Committees made a commitment to offer programs to Amish youth. The Committees assisted with the planning, teaching, and evaluation of day camp sessions. They coordinated the space, including seating, which was local Amish church pews, lunch for participants, and advertising in local Amish newspapers.

Promotion
When working with a collectivist society in centralized communities, mass promotion is unnecessary. Since the Amish do not believe in the use of technology, promotion is predominately through word-of-mouth and local Amish newspapers. Each year, attendance at the Holmes/Wayne Counties and the Geauga County Health and Safety Days increases without the use of promotion through modern technology, such as email, Internet, telephones, and television. Program staff was impressed at the response received through a simple 1/16-page print advertisement that appeared three weeks prior to each Health and Safety event. However, additional awareness must be attributed to the Amish Planning Committee members who announced dates and shared programming information with their friends and families at homes, places of business and church events.

Lessons Learned

Many lessons were learned throughout this initiative beginning with the project design. When conducting behavioral science research, even in the applied setting of program development, the Human Subjects Review process is mandated. Program staff was required to seek permission from parents to allow their youth to participate in the survey research.

One research activity precluded from implementation was the day camp evaluation form. As stated earlier, the required IRB parental permission forms made many Amish families change their perceptions of the day camp from its intended purpose as an educational study to a research study, and therefore, did want their children to attend the safety program. Program staff made every attempt to convey to Amish families that the permission form only allowed for program evaluations to be collected and reported. However, Amish families retained their skepticism of the motives hidden in the formal language presented in the permission forms. The end result was program staff forewent any opportunities to evaluate the day camp experience. The day camp programs were implemented without a formal evaluation component.

Not only did program staff learn first-hand about the Amish subculture in Ohio, but they also identified several barriers when working with this unique population. Program staff recognized that local support from the Amish community was crucial to the success of the project. Without such support, efforts would be limited and, perhaps, compromised. Working with Amish planning committee members required additional time for the planning process. After the initial contact was made to the local planning team, the program staff waited to learn when all committee members were able to meet. Without the convenience of communicating via email or phone, communication took longer.

Because of the educational and language differences in the Amish community, data collection processes required more time than estimated. Focus group discussions entailed extra time for introductions of program staff, in addition to a short presentation of the day camp model that is used with non-Amish children. Although an important aspect of a focus group is to make participants comfortable and open to share their comments candidly, the Amish participants needed to be at ease with the entire focus group process.

Typically in the Amish subculture, a spokesperson shares all comments as a representative voice for the others present. This subculture norm is not encouraged in focus group research. Focus group discussions are designed to encourage all participants to share opinions and comments. The diversity in discussion was a slow process to implement, and required the facilitator to personally call out individuals by name to hear their opinions of the questions posed.

Transcribing the focus group discussion required careful notation of the comments and reporting in the context stated as much as possible. Audio recordings of the focus groups were forbidden by the Amish participants because of their avoidance of technology. Therefore, two sets of notes were taken by two researchers during the discussions. The participants' heavy German accents made note-taking and translations challenging.

Likewise, language barriers existed in the needs assessment questionnaires. Nearly all survey research tools were adapted and conducted orally. This additional time was built into the programming, in that extra program staff attended the Health and Safety Day events specifically for data collection procedures.

One key lesson learned from the overall process was survey research was a very unfamiliar process for Amish participants. Within a collectivist society, expressing one's opinions publicly is uncommon, especially to non-Amish outsiders. Program staff worked patiently to nurture the audience for their feedback in each data collection method.

Conclusion

The safety day camp model was successful in educating Amish youth about rural hazards and injury prevention strategies. Although at the onset, the project seemed monumentally daunting for a young research team, the successful incorporation of a social marketing framework throughout the project's design made for an effective strategy for program development and evaluation. Collaborating with Amish populations in two different Ohio regions offering youth safety programs, gave the programming team confidence that similar programs could be implemented in other Ohio Amish communities.

This outreach intervention project demonstrated the core concepts of social marketing and its relative significance to the public safety model that was pilot-tested in two Amish communities. Program development strategies used qualitative and quantitative research methodologies in relation to the 4 Ps-Place, Price, Product, and Promotion factors. Replicating the safety day camp model in other Ohio Amish communities should be straightforward and less problematic based on the products developed in the pilot-tested communities. The partnerships and collaborations made with the Amish Safety Committee and Amish Health and Safety Day Planning Committees will benefit the project personnel positively as the Amish word-of-mouth promotion filtrates into other regions of Ohio. Because of the highly complimentary oral feedback from participants and requests for repeated programming, Amish leaders plan to continue the safety day camp program for their youth in future years.

Acknowledgement

This project was funded by the Youth Farm Safety Education and Certification Program (proposal 2006-41521-03730) through the USDA Cooperative State Research, Education, and Extension Service.

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References

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Author Information

Amy Beaudreault, MS, is a PhD candidate in the Department of Human and Community Resource Development at The Ohio State University and works as a Research Communication Specialist at Nationwide Children's Hospital.

Dee Jepsen, PhD, is an Assistant Professor and the State Agricultural Safety Leader in the Department of Food, Agricultural, and Biological Engineering at The Ohio State University.

Wayne Dellinger, MS, works as a Program Coordinator for agricultural safety projects in collaboration with Ohio's State Safety Office and the College of Public Health at The Ohio State University.

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Appendix

Appendix A. Amish Safety Focus Group Discussion Guide

[A short presentation will be given to participants of what a youth day camp program entails. Following the 5-7 minute presentation, the questions will begin.]

1. How are young people getting safety education now?
   • PROMPT: Would the day camp program be helpful/beneficial to the students?
2. What age groups should be targeted?
3. Who would be good instructors for the lessons taught at the day camps?
4. What is the best venue to teach safety programs to youth?
5. What type of incentives, prizes, or certificates (if any) would be appropriate and appreciated by youth who attend the day camp?
6. In your opinion, what safety topics would be important to include in the day camp program for young people?