Preventive Measures and Hygiene Habits of Apple Producers in the Prespa Region

Abstract

Background:

Agriculture is one of the most dangerous industries, both for the employees in that sector and for their families and the environment. The use of personal protective preventive measures and the maintenance of good hygienic practices are the basis for healthy production and healthy workers. The safety and hygiene of food products should be present during all stages of production.

Objectives:

The study aimed to assess the use of personal protective equipment (PPE) by apple growers during agricultural procedures as well as the hygiene habits of agricultural workers.

Subjects and Methods:

A cross-sectional study was conducted including 101 farmers from the Prespa region in the Republic of North Macedonia by using a questionnaire with 34 questions. The questions were formulated in order to give us an insight into the protective preventive measures undertaken at work by apple producers and their hygiene.

Results:

The study included 101 apple growers from the Prespa region. Wearing a completely tidy special PPE when using pesticides was registered in 78.2% of farmers, and when lawn mowing in 42.5%. 16% of the surveyed farmers during agricultural activities did not always wash their hands after going to the toilet, and almost 30% of them did not use soap when washing their hands.

Conclusion:

There is inadequate hygiene practice/personal hygiene during agricultural activities. In addition, the proper use of PPE is not at a satisfactory level and poses a risk to the health of apple growers.

INTRODUCTION

Apple production is essential for the Prespa region. Apple as the most common agricultural crop in the Republic of North Macedonia participates in 56% of the total fruit production.[1] The most important regions for apple production are the lake coastal regions (Prespa-Ohrid), due to the favorable agro-climatic conditions. Ninety percent of the total quantities of apples in the Republic of North Macedonia (MK) are produced in these places. Out of about 4.5 million apple trees in 2017, about 43,366 tons of apples were obtained.[2] According to the Food and Agriculture Organization (FAO), apples and apple products (juices, purees, cider, concentrates, and compotes) are ranked 17^th on the list of the highest-produced goods worldwide.[3] Due to the rich content of vitamins C, E, and A, but also the antioxidant properties of the natural compounds flavanol, catechin, flavonoids, etc., apples are one of the most recommended and favorite fruits worldwide.[4]

The widespread using pesticides is a public health problem. Many pesticides have been associated with health and environmental issues. Exposure to pesticides can be through contact with the skin, ingestion, or inhalation.[5] Uncontrolled and wrong use of pesticides can lead to the destruction of biodiversity, surface, and groundwater contamination, soil contamination, air contamination, and exposure to non-target vegetation.[6] Pesticides are a real challenge to human health. The risk is huge in developing countries. Prespa apple producers are in the risk group because they mix, load, transport, and apply pesticides and they have a risk for possible acute intoxications.[7] Pesticide acute exposure can cause acute health problems such as abdominal pain, dizziness, headaches, nausea, vomiting, as well as skin and eye problems.[8] The genetic alteration, diabetes mellitus, Parkinson's disease (PD), Alzheimer's disease (AD) and amyotrophic lateral sclerosis (ALS), reproductive disorders, lung cancer, multiple myeloma, non-Hodgkin's lymphoma, ovarian cancer, prostate cancer, rectal cancer, testicular cancer, and skin cancer are some of the effects due to chronic exposure of pesticides.[9] Occupational diseases are frequently related to acute and chronic pesticide exposure, so the use of personal protective equipment (PPE) is the best health and economically viable solution.[10]

Undoubtedly, taking care of human health in this long and laborious production process is of utmost importance and it should be our major task as health professionals. The farmers have an obligation, according to national Law for food safety, to place on the market safe food, without pesticides residues.

Hygiene habits in the food industry can be divided into three groups: personal hygiene, food hygiene and sanitation (food safety), and occupational hygiene. Personal hygiene has direct health effects on both the manufacturer and the users of the products.[11] Application of the principles of “Good Hygiene Practice” (GHP) and “Good Agricultural Practice” (GAP) are elementary for safe and healthy apples.[10]

In the Republic of North Macedonia, in the period from December 2013 to March 2014, with the approval of the Committee on Health and Environment, the Agency for Promotion of Agricultural Development, Public Health Centers and the Institute of Public Health organized joint courses for GHP and GAP for farmers. The main issues for education were the proper use of pesticides and fertilizers, the use of personal protective equipment, to distinct rotten and wholesome fruit, using clean containers for harvest and transporting apples, personal hygiene, but also about public health protection. This activity was very important because the farmers were not sufficiently informed and educated; they often had health problems and placed on the market products with pesticide residues.

AIM

The aim of this study was to determine habits for use of protective and preventive measures in apple producers Prespa region in the Republic of North Macedonia.

MATERIALS AND METHODS

This cross-sectional study was conducted in Resen and seven villages in the Prespa region involving apple growers during August and September 2020. A questionnaire included 34 questions. 32 of these with multiple choice answers and with the possibility to choose one answer. The other two questions were short answer questions about the place of living and a list of the uncovered parts of the body. The survey questionnaire was developed by the authors and was distributed to apple growers who gave their answers anonymously. The questionnaire was written in their mother tongue, the Macedonian language. The questionnaire was pretested by ten people. We didn’t ask for approval from Ethical committee, but all participants signed Informed consent. The questions were formulated in such a way as to give us an insight into the protective preventive measures at work and personal hygiene. We received answers from 101 respondents. 70% were conducted by a direct survey of respondents, while the other 30% by the distribution of survey questionnaires. The descriptive-statistical method was used in processing the results.

Statistical analysis of data was done with the statistical software SPSS for Windows 26,0. The data is shown with absolute and statistical numbers. The testing of the differences was done with the Chi-square test. The values of P < 0.05 were considered to be statistically significant.

RESULTS

A total of 101 respondents were surveyed, of which 83 were residents of the urban area Resen, and 18 were from seven villages in the Prespa region. Most of the participants were male 87 (86,13%) and 14 (13.87%) females.

The use of personal protective equipment when using pesticides had a noticeable deviation for the facial area and extremities, hence, we cannot say that wearing special clothing or a special face mask was satisfactory [Table 1].

Table 1:

Use of personal protective equipment when using pesticides

Type of protective equipment	Yes	Occasionally	No
Wearing special clothes	78.2%	8.9%	12.9%
Wearing a special face mask	86.1%	5%	8.9%
Wearing goggles	48.5%	9%	42.5%
Wearing gloves	59.4%	8%	32.6%

Chi-square=46.7 P<0.0001

The frequency of wearing or not wearing personal protective equipment while spraying pesticides differed significantly among participants with different types of protection (P < 0.0001).

The percentage of wearing personal protective equipment when lawn mowing was even lower. Even when it comes to wearing a special face mask and gloves, the percentage of not wearing them was higher than that of wearing [Table 2].

Table 2:

Use of personal protective equipment when lawn mowing in pre-harvest period

Type of protective equipment	Yes	Occasionally	No
Wearing special clothes and goggles	42.5%	13%	44.5%
Wearing a special face mask and gloves	29.7%	14.8%	55.5%

Chi-square=3.7 P=0.16

The frequency of wearing or not wearing personal protective equipment while lawn moving did not differ significantly among participants with different types of protection (P = 0.16).

Practicing healthy personal hygiene habits did not give us completely satisfactory answers. The highest percentage was observed in hand washing before eating and after performing a previous agricultural activity (95%), despite the use of soap when washing hands (70.3%) [Table 3].

Table 3:

Practicing personal hygiene

Hygiene habits	Yes	Occasionally	No
Hand washing before harvest	85.1%	11.9%	3%
Hand washing after toilet	84%	8%	8%
Hand washing before eating and after performing a previous agricultural activity	95%	1%	4%
Use of soap when washing hands	70.3%	8%	21.7%
Nail shortness, unpainted nails and tied hair	88.1%	11.9%	0%

67% of the Prespa apple producers wore clean work equipment every day and 71% always washed their hands with soap. But when asked if they washed their hands before eating, and after a previous agricultural activity, the percentage rose to 96.

In case of a hand injury, 41.6% did not cover with a waterproof patch against the color of the PPE, and in case of inflammation, open wound, or skin disease 53 out of 101 respondents were in contact with the product.

Ninety-nine respondents cleaned the apple storage rooms at least once a year, but 26% cleaned them once a week, and only 15% when cleaning these areas after sweeping washed them with salt, soap, or detergent.

DISCUSSION

Use of personal protective preventive measures and practicing good hygiene habits, complying with the Rulebook[12] on personal protective equipment used by employees, are of great importance for preventing diseases and injuries in apple growers. The Rulebook prescribes to use of special clothes, goggles, a face mask (or face protection during lawn mowing), and gloves during the using pesticides and lawn mowing.

Although in line with the requirements of the legislation and the indications of empirical and scientific data that the appropriate use of PPE significantly reduces side effects, and contributes to less health costs, the empirical and scientific data have proven to deviate from the use or proper use of PPE.[13] It is considered that in agriculture the greatest risk exists among workers who prepare pesticides for use (preparation of emulsions). Apple producers spray their apples at least ten times during the pre-harvest period from the end of March until the start of September. The recommended period for the last spray of apples with pesticides before harvesting is approximately 4 weeks, according to the label directions.[14] Stoleski et al.[15] found in their study that daily exposure in agricultural workers (not only apple producers) was formed 5 to 12 hours in season for use of pesticides. In the Republic of North Macedonia, in 2013, 20 injuries at work were registered in agriculture or fisheries, or 1.6% of all injuries at work in the Republic of North Macedonia. The ratio was 19:1 in favor of men.[16]

The use of personal protective equipment when spraying with pesticides is crucial to prevent possible side effects from pesticides. In workplaces where pesticides are produced and stored, in workplaces where different pesticide formulations are prepared, as well as in the vehicles with which they are transported, workers should wear personal protective equipment.[17] But our survey respondents did not fully adhere to the rules of proper use of personal protective equipment when using pesticides. Farmers are exposed to a number of preparations with different chemical compositions or simultaneous action of several substances with different toxicity and different mode of action, with the possibility of summarizing and emphasizing the action, and thus greater damage.[18]

The non-use or improper use of personal protective equipment when handling pesticides is a great problem not only in our country but also worldwide.[19] Acute pesticide poisoning is a global problem predominantly limited to developing countries.[20] About 1 million unintentional poisonings occur every year.[21] Older data has shown that 5 million people die each year worldwide from intentional, accidental, or occupational pesticide poisoning.[22] According to the regulations of the Republic of North Macedonia, occupational poisoning with organophosphorus pesticides (OFPs) is included in the List of occupational diseases (item 122).[23]

Since the earliest papers were published in 1967, it has been known that exposure to pesticides mostly occurs in a dermal way.[24] Contrary to the 2% proper use of PPE among Mexican farmers,[25] in our country its proper use in the investigated period was 57%. Unfortunately, 43% of our respondents said that their whole body was not covered. Of them, 29 stated that their eyes or facial area were not covered, and 33 their upper and/or lower extremities. According to Afshari et al.,[26] 59.7% never wore goggles, and according to an Indonesian study, 3.8% never wore goggles.[27] Meanwhile, the use of a special face mask when using pesticides in the review of Sapbamrer and Thammachai[28] was found to be 43.2%.

According to one Thai study[28] wearing a long-sleeved shirt 66.1% and pants that completely cover the lower extremities 71.1% were ranked highest in the PPE as the most widely used. On the other hand, overalls were rarely used, which was similar to Prespa apple growers. Iranian study showed that most farmers used trousers, blouses/shirts with long sleeves when spraying, but overalls and goggles were less commonly used. Given the regions identified, identical to the study by Bagheri et al.,[29] the most common symptoms would be eye burning and blurred vision. Also, in another study gloves, goggles, face masks, overalls, and protective masks were with a low rate of correct usage.[30] In our country, although the rate was higher, it cannot be said that it was satisfactory. Seventy-five of our respondents stated that they did not swallow, inhale or inject pesticide through their skin or eyes.

Apples may become contaminated from many sources, during picking, and storage and remain contaminated during processing. Because of that, we need from farm-to-table approach, including Good Hygiene Practice (GHP) and Good Agricultural Practice (GAP) for safe and healthy apples. Proper harvesting is the first step in reducing the potential for bacterial contamination. According to GHP and GAP standards the apple pickers and all others who handle fruit to use good hygiene, i.e. proper hand washing, avoiding touching the rungs on ladders where feet have been, etc.[31] Only 2% of Mexican agricultural workers had established healthy hygiene habits in agricultural activities.[25] The majority of the apple producers in our survey population said they did not practice good personal hygiene during the process of apple production. Adherence to healthy personal hygiene habits is the basis for healthy apple growers and the first link in the chain of prevention of, above all, infectious diseases such as fecal-oral diseases. Good hand washing with soap and water after spraying was registered in 57.4% of Iranian studies.[29] Twenty-two respondents responded that they did not wash their hands with soap during agricultural activities. This percentage of 22% is an alarm that serious education and training of this category of workers are needed.

According to J. Gomes et al.,[32] 83% of workers changed their clothes after work and the same percentage took a shower after work. In our country, 75% of respondents stated that they did not use the clothes intended for agricultural activities for other purposes. It is known that keeping work clothes clean, washing hands with soap, and wearing gloves help in reducing dimethyl alkyl phosphate (DMAP) and malathion dicarboxylic acid (MDA).[33]

Regarding the question about toilets in the apple storage rooms with toilets, the answers were almost similar, 53 had toilets, and 48 didn’t have toilets in warehouses. In fact, those 53% of respondents had a toilet, because the warehouses were in the close location of the workers’ houses. But the other half of respondents didn’t meet the rule to toilet facility with a hand sink available to employees in the orchard and no more than 500 meters.[34]

An Iranian study showed that 32.8% of farmers disposed of pesticide packaging in the fields.[29] The situation was similar in our country; 35 respondents did not have garbage disposal containers, while 66 respondents owned and regularly emptied the containers.

The limitation of this study is conducting most of the survey questionnaire face to face and had questions that were personal (especially when speaking about hygiene habits), which resulted in obtaining non-objective or partially objective answers.

CONCLUSION

Education and financial support for agricultural workers are necessary for the use of full and appropriate protective equipment, in order to have a healthy and safe working environment. But also to protect and improve public health. Supervision of the use of pesticides by competent authorities should be a priority in government policies. An integrated approach is needed in terms of inclusion, not only of the Ministry of Agriculture but also of the Ministry of Health and the Ministry of Labor.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.