Health Status of Children of Migrant Farm Workers: Farm Worker Family Health Program, Moultrie, Georgia

Abstract

Objectives. We evaluated the health status of migrant farmworkers’ children served by the Farm Worker Family Health Program (FWFHP) in Moultrie, Georgia.

Methods. We analyzed data from children aged 0 to 16 years examined through the FWFHP from 2003 to 2011 (n across years = 179–415). We compared their prevalence of overweight, obesity, elevated blood pressure, anemia, and stunting with that of children in the United States and Mexico.

Results. Across study years, prevalence of overweight, obesity, elevated blood pressure, anemia, and stunting ranged from 13.5% to 21.8%, 24.0% to 37.4%, 4.1% to 20.2%, 10.1% to 23.9%, and 1% to 6.4%, respectively. Children in the FWFHP had a higher prevalence of obesity than children in all comparison groups, and FWFHP children aged 6 to 12 years had a higher prevalence of elevated blood pressure than all comparison groups. Older FWFHP children had a higher prevalence of anemia than US children and Mexican children. Children in FWFHP had a higher prevalence of stunting than US and Mexican American children.

Conclusions. We observed an elevated prevalence of obesity, anemia among older age groups, and stunting in this sample of children of migrant workers.

Of the 1.4-million hired crop workers in the United States, 26% (364 000) are migrant, and 75% of foreign-born farmworkers are from Mexico.^1–3 It is estimated that 61% of these migrant farmworkers have incomes below the poverty line.⁴ Migrant farmworkers experience occupational hazards such as demanding physical labor, contact with poisonous plants and chemicals, and extreme weather conditions, and they are at increased risk of pesticide-related illness, respiratory illness, musculoskeletal disorders, and compromised reproductive and oral health.⁴ Many migrant farmworkers and their families also experience food insecurity.⁵

Children of migrant farmworkers also experience a variety of health risks and conditions. Primary care practitioners have rated Mexican American migrant children 2 to 3 times more likely to have poor or fair health as opposed to good or excellent health, compared with nonmigrant children.⁶ Intestinal parasites, nutritional deficiencies, dental problems, diarrhea, exposure to pesticides, and continuous cycles of otitis media leading to hearing loss are common among migrant farmworkers’ children.⁶

Not only do migrant farmworkers and their children experience increased health risks and food insecurity but they often also experience barriers to accessing health care. Among migrant families in North Carolina, 53% of the children had an unmet medical need; this was 24 times the proportion of US children overall and 15 times the proportion of Mexican American and Hispanic children.⁷ This study also found that 80% of children had not had a wellness check in the past year and 53% had not had one in more than 3 years.⁷ Limited transportation, lack of knowledge of where to go for care, lack of insurance, fear of wage deductions or job loss, language barriers, and scheduling conflicts with clinic hours contribute to limited access to health care.^4,7 In addition, fear of determination of employment ineligibility or deportation may cause migrant workers to be hesitant to seek social or health care services.⁸ With recent stricter legislation regarding immigrants in the United States, these factors may be further amplified.

There are approximately 400 federally authorized sites for migrant health care; however, these sites only serve 12% to 15% of the migrant population.⁴ Programs such as Emory University’s Nell Hodgson Woodruff School of Nursing’s Farm Worker Family Health Program (FWFHP) in the 4-county area of Colquitt, Cook, Brooks, and Tift, in Georgia, have been developed to help increase access to health care for migrant populations.

There is a lack of information on the health status of migrant farmworkers’ children in the United States. The purpose of this present study was to evaluate the health status of children of migrant farmworkers served by the FWFHP and to compare prevalence of overweight, obesity, elevated blood pressure, anemia, and stunting among FWFHP children to prevalence among all children in the United States, Mexican American children, and children in Mexico.

METHODS

Moultrie, located in Southwest Georgia, is the principal town in Colquitt County. According to the 2010 Census, Colquitt County had a total population of 45 498; 17.1% was Hispanic and 13.9% of the total population was Mexican. Furthermore, 22.4% of children aged younger than 18 years in Colquitt County are Hispanic.⁹ Approximately 7500 migrant and seasonal farmworkers reside in Colquitt County, half of whom are migrants.¹⁰ Of the civilian employed population aged older than 16 years, 6.4% works in farming, fishing, and forestry occupations in Moultrie, and Colquitt County is the top agricultural producer in Georgia, contributing the highest dollar value of production to Georgia’s total production value.^11,12 In 2007, there were 644 farms in Colquitt County, 199 of which had hired farm labor; of those that had hired farm labor, 19.1% had migrant farm workers.^13,14 Most migrant farm workers work on farms that produce vegetables, such as cabbage and greens, and others work on farms that produce row crops, with cotton and peanuts being the major products (Glenn Beard, Colquitt County Extension Agent, oral communication, August 30, 2012).

Farm Worker Family Health Program

The FWFHP is a 2-week cultural immersion service learning experience held each summer as a collaborative effort between health care and dental faculty and students from Emory University’s Nell Hodgson Woodruff School of Nursing, Georgia State University departments of physical therapy and psychology, the University of Georgia College of Pharmacy, and Clayton State University and Darton College departments of dental hygiene. In addition, the FWFHP collaborates with the Colquitt County Board of Education, Georgia Health District 8–2, and the Ellenton Farmworker Clinic. Ellenton Clinic provides a year-round health care resource for migrant workers in Colquitt, Cook, Brooks, and Tift Counties. The FWFHP program functions to provide health care, including “physical examinations, health screenings, health education, physical therapy, and dental care” to the predominantly Hispanic population of migrant farm workers and their families residing in Moultrie, Georgia.^8(p356) Children who are in the Colquitt County special program for children of migrant farmworkers summer school are recruited for the summer school by outreach workers who work in concert with the Southern Pine Migrant Education Agency. Parents of children attending the summer school are then offered the opportunity for their children to be seen by the FWFHP. Outreach and recruitment of children is continuous during the 2 weeks the FWFHP is held. All children whose parents agree for the child to receive health services by the FWFHP are offered all services available from the program.

Measurement of Variables

Undergraduate student nurses in the bachelor of science in nursing program at Emory University who were in their public health nursing course and who participated in the FWFHP conducted the health screenings. These students were trained on how to take measurements. All children were seen by nurse practitioner (NP) students who conducted a full physical examination. All examinations were reviewed and approved by faculty from Emory University. If any child’s measure was outside of normal, it was rechecked by the NP student, and if the measure was found to be out of range in a second measurement, the child was referred to the Ellenton clinic or the child’s primary care physician; transportation was arranged for immediate follow-up in the case of severely abnormal findings.

Children’s weight was measured and recorded in pounds after they removed their shoes and stood on an analog scale with both feet in the center of the scale. Height was measured with a wall chart after removing shoes with the child standing with feet flat and head, shoulders, buttocks, and heels against the wall. Body mass index (BMI; defined as weight in kilograms divided by the square of height in meters) for age was calculated with a BMI calculator. Blood pressure was measured with a manual calibrated sphygmomanometer and a stethoscope.¹⁵ If blood pressure was elevated on initial reading, a repeat measurement was taken; however, only the first blood pressure measurement was used for the purposes of this study. Hemoglobin was measured with a fingerstick method and according to manufacturer’s instructions with a HemoCue AB machine (Quest Diagnostics, Sweden).^16,17

We defined overweight as BMI percentile greater than or equal to the 85th percentile but less than the 95th percentile and obesity as BMI percentile greater than or equal to the 95th percentile.¹⁸ We defined elevated blood pressure as systolic or diastolic blood pressure or both greater than or equal to the 95th percentile based on age, height, and sex.¹⁵ We defined anemia on the basis of criteria set by the Centers for Disease Control and Prevention according to age, sex, and hemoglobin level, and we defined stunting as less than or equal to a minus-2 z score for height for age.^17,19

Statistical Analysis

We analyzed data from children aged 0 to 16 years examined during the FWFHP from 2003 to 2011 (n across years = 179 to 415). We excluded children missing information on date of birth, height, or weight from analysis. We excluded children missing information pertinent to outcome variables from analysis for the corresponding outcome. We used SAS version 9.3 (SAS Institute, Cary, NC) for all data analyses. We analyzed each year of data separately to obtain descriptive statistics of the outcome variables.

We used the Pearson correlation to test for correlations among systolic blood pressure and diastolic blood pressure and age, height, weight, and BMI. We categorized children into age groups to facilitate comparisons with other data. We used the χ² and Fisher exact tests and the Bonferroni posthoc analysis to test for significant differences (α = 0.05) in the prevalence of outcome variables between years and designated age groups within each year. Certain years were then combined to allow for a larger sample size and to correspond with years examined in comparison data.

Comparison Data

For purposes of comparison, we chose age-specific groups to correspond with the age groups reported in the available comparison data. The range of years and age ranges differ on the basis of those used in comparison data.

We used the National Health and Nutrition Examination Survey (NHANES) as comparison data for prevalence of overweight, obesity, and elevated blood pressure. NHANES is nationally representative of the US civilian population.²⁰ Data were previously collected and analyzed for overweight and obesity prevalence on a sample of 3281 children and adolescents aged 2 to 19 years during the 2007–2008 survey period.²⁰ Data were also previously collected and analyzed for elevated blood pressure prevalence on a sample of 4427 children and adolescents aged 8 to 17 years during the 2003–2006 survey period.²¹

We used the Mexican National Health and Nutrition Survey 2006 (ENSANUT) as comparison data for overweight, obesity, anemia, and stunting among Mexican children. ENSANUT is nationally representative of children, adolescents, and adults in Mexico.²² Data were previously collected and analyzed on a total sample of 36 626 children and adolescents aged 0 to 19 years for the 2006 survey.^22,23

We used the Pediatric and Nutrition Surveillance System as comparison data for anemia based on hemoglobin among low-income infants and children aged younger than 5 years in the United States.²⁴ Data were previously collected and analyzed for prevalence of anemia based on hemoglobin and hematocrit from a sample of 5 391 027 children aged younger than 5 years in 2010.²⁴

We used a non–nationally representative retrospective cross-sectional study for comparison data for anemia based on hemoglobin among 2131 children aged 1 to 23 years sampled from an inner-city pediatric emergency department in the United States.²⁵ We also used 2 non–nationally representative studies as comparison data for elevated blood pressure among children in Mexico. One study was conducted among 329 school children aged 6 to 12 years in Sabinas Hidalgo, a city in the Mexican state of Nuevo Leon.²⁶ The second study was conducted among 252 children aged 6 to 13 years in Guerrero, Mexico.²⁷ We used World Health Organization data to compare prevalence of stunting.²⁸

RESULTS

The number of children studied each year ranged from 179 to 415. The proportion of males ranged from 46.4% to 56.4%. The children were aged 0 to 16 years (mean 7.7 years; Table 1).

TABLE 1—

Characteristics of Children Served by the Farm Worker Family Health Program: Moultrie, GA, 2003–2011

Characteristics	2003 (n = 415), % or Mean SD	2004 (n = 414), % or Mean SD	2005 (n = 358), % or Mean SD	2006 (n = 179), % or Mean SD	2007 (n = 220), % or Mean SD	2008 (n = 182), % or Mean SD	2009 (n = 234), % or Mean SD	2010 (n = 278), % or Mean SD	2011 (n = 183), % or Mean SD
Male	54.5	56.4	55.2	46.4	49.3	53.0	53.5	52.0	49.5
Age, y	7.7 (2.8)	7.8 (2.9)	8.1 (3.0)	8.2 (3.2)	7.7 (3.4)	7.8 (3.1)	7.5 (2.8)	7.1 (2.7)	7.3 (3.2)
BMI percentile	71.4 (28.1)	73.2 (28.7)	72.0 (27.5)	76.6 (26.2)	71.6 (26.7)	71.4 (30.4)	67.1 (32.4)	69.8 (30.4)	70.7 (33.1)
Overweight
All	17.8	17.4	18.6	21.8	21.1	17.9	13.5	14.6	17.6
Sex
Male	17.5	18.9	20.0	22.0	20.2	18.8	12.3	14.6	17.8
Female	18.1	15.5	17.0	21.7	21.9	16.9	15.0	14.6	17.4
Age
2–5 y	18.9	18.1	11.1	6.5a	27.3	8.0	4.8b	12.1	13.0
6–11 y	17.8	16.0	22.2	26.5a	21.5	20.0	17.2b	15.5	18.9
12–16 y	15.0	23.4	15.8	19.2	9.1	29.2	14.3	17.4	26.1
Obesity
All	24.8	31.5	25.1	31.0	24.0	30.1	29.7	30.7	37.4
Sex
Male	29.6c	33.8	26.7	51.9	25.3	31.3	34.4	31.4	45.6d
Female	19.1c	28.7	23.3	48.2	22.9	28.9	24.3	30.0	29.4d
Age
2–5 y	18.9	24.8	17.3	25.8	18.2	18.0	17.5e	25.3	21.7f
6–11 y	27.3	35.2	26.4	31.6	24.8	35.2	33.8e	32.9	47.8f
12–16 y	25.0	27.7	31.6	34.6	27.3	33.3	38.1	34.8	43.5
Elevated blood pressure
All	6.8h,I	12.4g	8.7h	20.2h	4.1g,h,j	12.6	16.4i	6.9h,I	14.8j
Sex
Male	9.3k	16.3l	9.7	19.3	2.8	7.3m	19.4	6.9	17.8
Female	3.7k	7.2l	7.6	21.1	5.4	18.8m	13.0	6.8	12.0
Age
6–12 y	6.7	11.4n	7.8	23.1	2.5	13.7	14.8	7.4	16.5
13–16 y	4.6	32.0n	15.6	0	7.1	15.4	42.9	0.0	10.0
Anemia
All	23.3°	23.0p	21.7	13.1	19.8	16.2	23.9q	14.5	10.1o,p,q
Sex
Male	22.2	27.4	20.9	10.1	20.4	14.9	26.0	16.3	10.5
Female	24.6	17.4	21.8	15.9	19.4	17.5	21.7	12.6	9.8
Age
0–4 y	17.3	25.6	26.5	4.4	20.7	14.3	5.9	21.4	4.9
5–8 y	29.5r	20.8	24.4	14.5	25.0	21.1	21.3	9.0	7.0
9–11 y	20.9	24.6	20.4	10.7	16.7	10.9	28.1	16.1	14.9
12–16 y	7.5r	22.2	13.6	22.2	12.5	12.5	40.0	27.3	17.4
Stunting
Height-for-age z score, mean (SD)	−0.3 (1.0)	−0.2 (1.1)	0.0 (1.5)	−0.2 (1.2)	−0.3 (1.1)	0.5 (1.2)	0.7 (2.3)	0.3 (1.5)	0.4 (1.5)
All	4.6	4.5	3.7	6.3	6.4	1.1	1.8	2.2	5.0
Sex
Male	4.0	5.7	4.1	6.1	5.0	0.0	0.8	2.3	3.3
Female	5.3	2.9	3.1	6.5	7.6	2.4	2.8	2.2	6.5
Age, y: 0–4.9	7.5	6.7	2.5	3.2	6.1	0.0	0.0	1.2	2.9

Note. BMI = body mass index. Pairs that share a superscript differ at P < .05.

The mean BMI percentile each year ranged from 67.1 to 76.6, the prevalence of overweight ranged from 13.5% to 21.8%, and the prevalence of obesity ranged from 24.0% to 37.4%. There was no trend over time in the prevalence of overweight among males and females or among age groups. Males had a higher prevalence of obesity compared with females, and children aged 2 to 5 years had the lowest prevalence of obesity (Table 1). Study children had a lower prevalence of overweight compared with all children in the United States and to Mexican American children across all 3 designated age groups, 2 to 5 years, 6 to 11 years, and 12 to 19 years. Compared with children in Mexico, FWFHP children had a lower prevalence of overweight in age groups 2 to 5 years and 12 to 19 years but a higher prevalence of overweight in the 6-to-11-year age group (Table 2). Children in the FWFHP had a higher prevalence of obesity compared with all children in the United States, Mexican American children, and children in Mexico across all 3 designated age groups—2 to 5 years, 6 to 11 years, and 12 to 19 years (Table 2).

TABLE 2—

Comparison of Overweight and Obesity Prevalence Among Children Served by the FWFHP in Moultrie, GA, With All US Children, Mexican American Children, and Children in Mexico: 2005–2009

Characteristics	Children in FWFHP, 2005–2009	All US Children From NHANES, 2007–2008	Mexican American Children From NHANES, 2007–2008	Children in Mexico From ENSANUT, 2006
Overweight, %
2–5 y	10.2	21.2*	27.7*	12.5
6–11 y	21.2	35.5*	41.7*	17.3*
12–19 y	16.8	34.2*	44.1*	23.7*
Obesity, %
2–5 y	18.2	10.4*	13.7*	4.2*
6–11 y	29.4	19.6*	24.7*	8.9*
12–19 y	31.6	18.1*	22.2*	8.8*

Note. ENSANUT = Mexican National Health and Nutrition Survey; FWFHP = Farm Worker Family Health Program; NHANES = National Health and Nutrition Examination Survey. NHANES age ranges were 2–5, 6–11, and 12–19 years.²⁰ ENSANUT age ranges were 2–4, 5–11, and 12–18 years.²²

*Indicates a prevalence that is significantly different from the corresponding prevalence among the FWFHP study population where P < .05.

The prevalence of elevated blood pressure ranged from 4.1% to 20.1% (Table 1). Both systolic blood pressure and diastolic blood pressure were correlated with age, weight, and BMI. There was no trend over time in the prevalence of elevated blood pressure among males and females or among age groups (Table 1). Study children had a higher prevalence of elevated blood pressure compared with all children in the United States and to Mexican American children across both age categories, 6 to 12 years and 13 to 17 years. Compared with children in Sabinas Hidalgo, Nuevo Leon, Mexico, and to children in Guerrero, Mexico, FWFHP children aged 6 to 12 years had a higher prevalence of elevated blood pressure (Table 3).

TABLE 3—

Comparison of Elevated Blood Pressure Prevalence Among Children Served by the FWFHP in Moultrie, GA, With All US Children, Mexican American Children, and Children in Mexico: 2003–2008

Age, y	Children in FWFHP, 2003–2008, %	All US Children From NHANES, 2003–2006, %	Mexican American Children From NHANES, 2003–2006,%	Children in Sabinas Hidalgo, Mexico, 2007, %	Children in Guerrero, Mexico, 2008, %
6–12	9.9	3.4*	2.0*	4.9*	4.7*
13–17	14.0	2.6*	2.1*	…	…

Note. FWFHP = Farm Worker Family Health Program; NHANES = National Health and Nutrition Examination Survey. NHANES age ranges were 8–12 and 13–17 years.²¹ Sabinas Hidalgo, Mexico, age range was 6–12 years.²⁶ Guerrero, Mexico, age range was 6–13 years.²⁷

*Indicates a prevalence that is significantly different from the corresponding prevalence among the FWFHP study population where P < .05.

The prevalence of anemia ranged from 10.1% to 23.9%. There was no trend over time in prevalence of anemia between males and females or among age groups (Table 1). Study children had a lower prevalence of anemia compared with all children in the United States and to Hispanic American children aged 0 to 4 years sampled by the 2010 Pediatric and Nutrition Surveillance System. Children in FWFHP aged 0 to 4 years had a lower prevalence of anemia compared with children in the United States aged 1 to 4 years sampled from an inner-city pediatric emergency department; however, FWFHP children had a higher prevalence of anemia compared with children in the United States sampled from an inner-city pediatric emergency department among age groups 5 to 11 years and 12 to 16 years. Compared with children in Mexico, study children had a lower prevalence of anemia among ages 0 to 4 years and 5 to 8 years but a higher prevalence of anemia among ages 9 to 11 years and 12 to 16 years (Table 4).

TABLE 4—

Comparison of Anemia Prevalence Among Children Served by the FWFHP in Moultrie, GA, With All US Children, Mexican American Children, and Children in Mexico: 2006–2010

Age, y	Children in FWFHP, 2006–2010, %	All US Children From PedNSS, 2010, %	All US Children, 2006–2007, %	Hispanic American Children From PedNSS, 2010, %	Children in Mexico From ENSANUT, 2006, %
0–4	11.2	14.6	14.8	13.6	23.7*
5–8	15.2	…	13.4	…	20.8*
9–11	15.8	…		…	14.7
12–16	21.5	…	14.0*	…	8.5*

Note. ENSANUT = Mexican National Health and Nutrition Survey; FWFHP = Farm Worker Family Health Program; PedNSS = Pediatric and Nutrition Surveillance System. PedNSS age range was 0–4.9 years.²⁴ All US children 2006–2007 age ranges were 1–4, 5–12, and 13–23 years.²⁵ ENSANUT age ranges were 1–4, 5–8, 9–11, and 12–19 years.^22,23

*Indicates a prevalence that is significantly different from the corresponding prevalence among the FWFHP study population where P < .05.

The mean height-for-age z score ranged from −0.3 to 0.7, and the prevalence of stunting ranged from 1.1% to 6.4%. There was no trend in the prevalence of stunting between males and females (Table 1). From 2003 to 2006, study children aged 0 to 4.9 years had a significantly different prevalence of stunting compared with all comparison groups (P < .05). Children in FWFHP had a higher prevalence of stunting compared with all children in the United States and Mexican American children from 1999 to 2002 as reported by the World Health Organization (5.4% vs 3.3% and 2.4%, respectively).²⁸ However, FWFHP children had a lower prevalence of stunting compared with children in Mexico (5.4% vs 15.5%, respectively).²²

DISCUSSION

The migrant children who participated in the FWFHP in Moultrie, Georgia, had a higher prevalence of obesity than of overweight from 2003 to 2011, and the prevalence of obesity each year was higher than the prevalence of obesity among all children aged 2 to 19 years in the United States from 2007 to 2008.²⁰ Furthermore, FWFHP children had a higher prevalence of obesity than all children in the United States, Mexican American children, and children in Mexico. This is consistent with findings from other studies that have found a higher prevalence of overweight and obesity among Mexican immigrant and Mexican American children.^20,29 Children in the FWFHP are among a unique population in the United States because of many factors, such as experiencing occupational hazards, poverty, food insecurity, language barriers, acculturation difficulties, and decreased access to health care, which may all contribute to increased obesity prevalence in this population.

Children in the FWFHP had a higher prevalence of elevated blood pressure compared with all US children, Mexican American children, and children in Mexico. One possible reason for the high prevalence of elevated blood pressure is that, for purposes of this study, elevated blood pressure was defined by the initial blood pressure reading instead of the recommended 3 separate readings, and blood pressure is frequently elevated during this first reading.¹⁵ Therefore, future studies should include all blood pressure measurements to more accurately reflect the prevalence of elevated blood pressure among this population. There are no nationally representative data on elevated blood pressure among children in Mexico. However, 2 different non–nationally representative studies yielded results similar to each other.

Children in FWFHP aged 5 to 16 years had a higher prevalence of anemia compared with those in the United States aged 5 to 23 years. Children in FWFHP aged 9 to 16 years also had a higher prevalence of anemia compared with children in Mexico aged 9 to 19 years. Therefore, the prevalence of anemia among these migrant children in older age groups may be of concern and deserve more attention. Because hemoglobin is the only marker used to identify anemia, the cause of anemia among the FWFHP children is unknown and may be infectious or nutritional, including iron, folate, and B₁₂ deficiencies.³⁰ A limitation in the comparison of anemia prevalence is that comparison data for the prevalence of anemia among children in the United States is only nationally representative among all children in the United States and Mexican American children aged 0 to 4 years, whereas the prevalence of anemia among all children aged 5 to 8 years, 9 to 11 years, and 12 to 16 years in the United States is based on non–nationally representative data. However, the prevalence of anemia among all US children aged 0 to 4 years is similar among the nationally representative and non–nationally representative studies.

Children in FWFHP had a higher prevalence of stunting compared with all US children and Mexican American children; however, the FWFHP children had a lower prevalence of stunting than children in Mexico. This suggests that migrant children are subject to the stunting associated with early childhood in Mexico and some catch-up growth when living in the United States.

The number of children seen each year during the FWFHP program varied. This was attributable to variability in the funding available for the summer school program for migrant farmworkers’ children, from which children are recruited for the FWFHP. The variability in funding affected the length of summer school and the number of children attending the summer school program each year. For the purposes of this study, we focused on the physical examination and laboratory component of available clinical information. Because the FWFHP is a screening program, a complete medical history is not obtained on all of the children; however, obtaining a medical, dietary, and physical activity history would help in better understanding the health status of this population.

In conclusion, we observed an elevated prevalence of obesity, elevated blood pressure, anemia among older age groups, and stunting in this sample of children of migrant workers. There is a need for further investigation into the underlying causes to implement effective prevention and treatment strategies in this unique population.