ROPS commentary—Addressing our fatal blind spot: Applying evidence-based solutions to reduce the most frequent cause of death on U.S. farms

Abstract

Tractor overturns are the most prominent contributing factor to death on U.S. farms and have been for decades. While public health researchers hypothesized years ago that overturn fatalities would largely disappear as older tractors were replaced by newer ones, this has not happened. In the meantime, farmers continue to die in these easily preventable and tragic events. Not only are tractor rollover protective structures (ROPS) 99% effective in preventing death in the event of an overturn, a national program exists to connect farmers with ROPS. While this program has been popular with farmers, and the cost-effectiveness of providing farmers with technical support and cost-sharing rebates has been demonstrated, many states lack access to ROPS rebates, even those states with the highest number of overturn fatalities. Given the evidence, it is difficult to reconcile the lack of policy or public investment in a solution that decisively addresses the most pernicious contributor to death in the agricultural industry. In this commentary, we highlight the science behind this proven solution to tractor overturns and the essential role that the media and implementation science can play in encouraging policymakers to save lives.

1 ∣. TRACTOR OVERTURNS: DEADLY, BUT PREVENTABLE EVENTS

We know how to prevent one of the most common causes of workplace injury and death in one of the country's most dangerous industries—but the solution is not being implemented. As documented in many studies of tractor overturns, public health researchers have repeatedly established the sad reality that tractor overturn events have been, and continue to be, the most frequent cause of death on U.S. farms.¹ In 2018, the U.S. Bureau of Labor Statistics (BLS) documented 146 tractor-related fatalities.² Although this is the lowest reported number of annual fatalities since 2011, tractor-related fatality rates continue to fluctuate from year to year. With the installation of rollover protective structures (ROPS), these deaths could be virtually eliminated.^3,4 Prior studies have estimated that for every overturn fatality, up to seven overturn injuries occur, with approximately half of these estimated to cause permanent disability. Each one of these deaths and disabling injuries holds significant consequences for farmers, their families, and their communities.⁵ Unfortunately, these estimates are also likely conservative, as BLS fatality statistics often fail to capture the true extent of the fatality and injury burden in the agriculture industry.^6,7

What we do know is that addressing the consequences of tractor overturns could significantly reduce agricultural fatality rates. There is a broad body of scientific literature establishing that a solution is readily at hand. The evidence compiled over decades of research on this topic has determined:

1. That the installation of ROPS is 99% effective when used with a seatbelt, and even extremely effective when a seatbelt is not used (as demonstrated in both engineering tests and epidemiological studies of death certificate data).⁸

2. That as the prevalence of ROPS on tractors increases, a concomitant decrease in a tractor overturn fatalities is seen; for example, in countries such as Sweden and Australia where policymakers offered combinations of incentives and legislation to require installation.^9,10

3. That although roughly one-half to one-third of U.S. tractors lack these devices,¹ farmers are willing to install them when the appropriate mix of financial and logistical support is provided.¹¹

4. That programs designed to increase ROPS installations not only save lives but can lead to substantial monetary savings when program costs are measured against savings in injuries and fatalities averted.^5,12

2 ∣. A PROGRAM THAT WORKS: THE NATIONAL ROPS REBATE PROGRAM

The National ROPS Rebate Program (NRRP) provides a perfect case study. The program was launched in 2014 and provides logistical support, such as a toll-free hotline and website, to assist farmers with installing ROPS. Financial support for the purchase of ROPS is also offered to farmers in states that choose to invest in ROPS rebate programs.

The NRRP was the culmination of many years of collaboration, development, evaluation, and implementation research, and checks many of the boxes that implementation scientists highlight as crucial factors for success. For example, the program relied heavily on community-based research in the development phase. Extensive interviews were conducted with farmers regarding barriers and potential facilitators to installing ROPS. The program also built widespread support from stakeholders: the NRRP was launched under the auspices of a national coalition of stakeholders representing industry, government, manufacturers and other key groups, and funding for ROPS rebate programs is currently included as a policy resolution for the American Farm Bureau Federation. Finally, the program applied a pragmatic and considered approach to scaling up from a state-based, to a regional and then to a national program.¹³

Throughout this process, the program has repeatedly demonstrated its effectiveness in the “real world.” For example, customer satisfaction surveys have demonstrated that it is popular among farmers; 99.5% would recommend the program to other farmers. Surveys with farmers who participated in the program demonstrate that lives were saved and injuries were averted.⁵ The program was recognized as an effective strategy for addressing tractor overturns by the National Institute of Occupational Safety and Health Director in 2010¹⁴ and the research leading up to the development and expansion of the program was also cited in a prior AJPH editorial as, “a best practice example of implementation research.”¹⁵ Even policymakers have recognized the program's potential. Senator Charles Schumer has been an outspoken supporter of the NRRP and has recognized the NRRP's important potential for addressing the most frequent cause of farm death.

Despite this body of evidence, there are few states that provide the financial support necessary for farmers to purchase ROPS through the program, and for those that do, the majority lack sufficient funds. This is noteworthy given that the logistical support provided through the NRRP is paid by federal grants, which assures that any state investments made in these programs go directly to their state's farmers or cover the promotion of the program. For states like New York, which have offered ROPS rebate programs for decades, appropriations have amounted to roughly $250,000 per year and have still kept pace with demand, arguably a minimal investment for most state budgets. In light of the support provided by the NRRP and the minimal funding required, it would seem that states, especially those that have the highest risk of overturn fatalities, would welcome funding for ROPS rebates. On the contrary, there are nearly 2000 farmers on a wait list for ROPS rebate funding and many of these individuals reside in states with the highest risk for overturn fatalities, including Iowa, Missouri, and Kansas.

Moreover, ROPS access reflects important gaps in health equity, as the individuals who can least afford these protective devices are at the greatest risk. Prior studies on ROPS prevalence have pointed to pockets of elevated risk, such as small farms or farms in the Midwest.^16,17 Increased risk of tractor-overturn fatality has also been identified among particular sub-groups, such as older men, part-time farmers, and farms with low-profit margins.^18-20 These risks track the history of machinery design, as tractors manufactured after 1986 are sold with ROPS already installed and farms that are financially well-off can typically afford to invest in newer equipment.

3 ∣. OPERATIONALIZING EVIDENCE-BASED SOLUTIONS: IMPLEMENTATION SCIENCE

In the United States, billions of dollars are dedicated annually to the identification and resolution of health and safety issues like tractor overturns. Public health researchers and practitioners are largely tasked with developing the prevention agenda and hold the responsibility for prioritizing public health problems, as well as developing solutions that will lead to improved population health outcomes. In the past, and even to some extent in the present, the public health community has operated under the assumption that conducting rigorous research and identifying “evidence-based” solutions is all that is needed to address these problems. In other words, if you develop a sound strategy and demonstrate that it works, target populations and policymakers will naturally adopt it.

Unfortunately, the literature demonstrates that the widespread adoption of evidence-based practices or solutions is often the exception, not the rule. As a result, the public health community has increasingly acknowledged that there is a good deal more that is required beyond creating solutions. In a review, Glasgow and Emmons cite research that shows roughly half of evidence-based healthcare practices are actually implemented while even fewer prevention or behavioral interventions are instituted.²¹ Various estimates of the successful translation of occupational health and safety evidence-based solutions indicate roughly one-fifth are actually used by workers.^22,23

The gap between developing evidence for public health approaches and putting these into practice has been increasingly discussed in epidemiological research. As stated by Glasgow and Emmons, “Translating results to influence public health practice and policy requires explicit attention to the real-world challenges of implementation and scaling up.”²¹ This has led to the development of a research field entirely dedicated to understanding these real-world challenges, the field of implementation science. As these researchers have demonstrated, it is not enough to show that an intervention works in a controlled and confined setting, or even to demonstrate that the solution has broad appeal. The NRRP provides evidence for this conclusion.

4 ∣. MEDIA: LEADING THE NRRP FROM OBSCURITY TO THE SPOTLIGHT

Findings on the effectiveness of ROPS are especially poignant given the results of a recent study of news coverage about farm safety and tractor rollovers in states with some of the highest risk of overturn death (Iowa, Missouri, and Kansas). Researchers found that two-thirds of news articles about farm safety were completely devoid of reporting about solutions for improving farm safety.²³ Only 10% of all articles explicitly named ROPS, and in Kansas, there was no discussion of ROPS in news coverage at all. Government officials and policymakers quoted in these articles did not mention ROPS or the importance of support for programs that increase access to this lifesaving equipment. Just two of the articles named the NRRP and the benefits the program provides, such as logistical and financial assistance. In short, ROPS and programs like the NRRP are almost completely absent in farm safety coverage in the U.S. media, despite a plethora of evidence supporting these programs.

This begs the question: How much evidence is enough to facilitate widespread and substantive change? While research has demonstrated that the cost of doing nothing is substantial (emotionally, physically, and financially)²⁴ and an easily-implemented solution exists, thousands of farmers wait for ROPS rebate funding, many for years. At this point, public health researchers have done what they can to develop a solution and demonstrate that it works. It is now up to policymakers to do the right thing and put evidence into action. However, the absence of news stories that include ROPS and the NRRP in the media's coverage of farm safety challenges is troubling. In Minnesota where a ROPS Program was funded in 2016, “[Representative Clark] Johnson and other lawmakers said they were prompted to act by a 2015 series in the Star Tribune that revealed a disturbing spike in the number of Minnesota farmers killed in work-related accidents.”²⁵ In areas without news coverage, many policymakers will not learn about ROPS' lifesaving potential for their constituents. Even if they do, without media attention the issue lacks the urgency necessary for creating tension for change.²⁶

Looking in the rearview mirror at the past few decades, we know that if we do nothing to increase the installation of ROPS on older farm tractors, overturns are likely to continue to be the single greatest contributor to farm fatalities. We also know that these deaths are preventable, that ROPS are effective and that programs like the NRRP increase ROPS installations in ways that are cost-effective and acceptable to farmers. However, we also know that demonstrating the value of programs like these can only take us so far. By combining the strategies and methods of implementation science (a field of science that is dedicated to translating evidence into action), with media coverage (an effective channel for demonstrating the need for change) it may just be possible to convince policymakers to invest in these proven solutions. If so, the combination of implementation science and media coverage may prove to be a game-changer for the field of public health and could put an end to the needless deaths of America's farmers.

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.