Copyright © 2019 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited Attending to Pesticide Exposure and Heat Illness Among Farmworkers Results From an Attention Placebo-Controlled Evaluation Design Joseph G. Grzywacz, PhD, Melinda Gonzales-Backen, PhD, Amy Liebman, MPH, Antonio J. Marı ´n, MA, Maribel Trejo, BS, Cecilia Ordaz Gudino, Jeannie Economos, and J. Antonio Tovar-Aguilar, PhD Objective: The aim of this study was to determine the effectiveness of curricula for improving knowledge and attitudes pertaining to pesticide exposure and heat illness among immigrant Latino farmworkers. Methods: A pesticide safety curriculum informed by the revised Worker Protection Standard (WPS) was tested against an attention placebo-con- trolled curriculum (heat illness) in a sample of Latino farmworkers (N ¼ 127). Results: Pesticide safety knowledge increased in the overall sample, but did not differ by curriculum assignment. Pesticide safety behavioral intentions increased among participants in the pesticide safety curriculum but decreased among those in the other curriculum (P < 0.05). Heat illness knowledge and behavioral intentions increased more for farm- workers assigned to the heat illness than the pesticide safety curriculum. Conclusion: The developed curricula show good promise for meeting the spirit of the revised WPS and for reducing the burden of heat-related fatality and morbidity among Latino farmworkers. Keywords: EPA Worker Protection Standard, farmworkers, health-related illness, pesticide safety F armworkers, the vast of majority of whom are immigrants from Mexico, are a vulnerable worker population. Pesticide exposure and heat illness are among the top occupational health threats confronted by farmworkers. Arcury et al 1,2 clearly documented that the vast majority of farmworkers have evidence of exposure to multiple pesticides across the agricultural season. Although the health effects of chronic, low-dose exposure to pesticides are largely unknown, epidemiological research and that undertaken with ani- mal models suggest that elevated pesticide exposure increases the risk of neurological conditions such as Parkinson disease 3,4 and fertility problems, 5,6 as well as a variety of cancers. 7,8 Whereas the health effects of pesticides are primarily long-term in nature, farm- workers are among the most at-risk worker populations for heat- related death while on the job. Indeed, whereas the average rate of heat-related fatality is 0.22 per 1 million workers in the general workforce, it is 3.06 in the agricultural sector, 9 a nearly 14-fold increased risk. The United States Environmental Protection Agency (US EPA), after an extensive public comment period that included comments from farmworker advocates and other stakeholders, 10 revised the Worker Protection Standard (WPS) in 2015. The WPS is the only federal regulation designed to minimize farmworkers’ exposure to pesticides by requiring worker training. The revised WPS required an expansion in the content of the required training, as well as changes to the timing and frequency of training. Previ- ously, employers were required to provide training to workers at least once every 5 years, and the longest a farmworker could wait to be trained before beginning work in areas where pesticides were used was 5 days. The revised WPS requires an annual training before any work was done in the fields or greenhouses and the regulation requires pesticide health and safety training once a year. The majority of the provisions of the revised WPS became active in 2017 with the commencement of training with the updated curricu- lum required in 2018. Throughout its 40-year existence, WPS training has occurred in two primary ways. The first and predominant mode of training was through educational video. The second primary delivery was through formal health and safety education sessions using an EPA- certified curriculum. Evaluations of WPS training, via either video or health educator, are notably absent from the peer-reviewed literature. Indeed, there are only three evaluations of WPS training in the literature. Anger et al, 11 using a single-sample, pre-posttest design reported an immediate change in Latino vineyard workers’ knowledge about pesticides and strategies for minimizing pesticide exposure following a computer-disseminated WPS lesson. They also showed that a small proportion of that knowledge was retained across a 5-month period. Another evaluation using a similar single- sample pre-posttest design but using the Pesticide and Farmworker Health Toolkit, a curriculum approved by the U.S. EPA for meeting requirements of the original WPS, deployed via trainers reported similar results. 12 Vela Acosta et al 13 wait-list control design with pre-post assessment reported greater increases in pesticide knowl- edge and readiness to change pesticide-related behaviors among individuals receiving immediate education, featuring an EPA- approved WPS flipchart, relative to wait-list controls. Quandt et al 14 evaluation of La Familia Sana, a WPS-based curriculum focused on para-occupational exposure to pesticides deployed via a community health worker, found increases from pre- to posttest in knowledge and behaviors advocated by the WPS to reduce pesticide exposure. Otherwise, research on the WPS has largely been descrip- tive in terms of whether WPS training was provided with clear evidence that training was far from universal. 15–17 No evaluations of safety education programs designed to prevent heat illness among farmworkers could be located in the peer-reviewed literature. Entrenamiento de Pesticidas e Insolacio ´n que es Cultural- mente Apropiada (PISCA) was designed to provide a tool to effectively reduce poor occupational health outcomes among farm- workers. The central feature of the tool is two safety education curricula: one targeting pesticide exposure and the other heat illness. PISCA curricula were designed based on two fundamental princi- ples. Foremost, following the early recommendations of Quandt et al, 18,19 both curricula (ie, WPS and Heat illness) were designed to maximize cultural appropriateness. Beyond simply translating the From the Florida State University, Department of Family & Child Sciences, Tallahassee, FL (Dr Grzywacz, Dr Gonzales-Backen, Marı ´n, Trejo, Gudino), Migrant Clinicians Network, Division of Environmental and Occupational Health, Salisbury, MD (Liebman), Farmworker Association of Florida, Apopka, FL (Economos, Dr Tovar-Aguilar). This research was supported by a grant to the Southeastern Coastal Center for Agricultural Health and Safety (U54 OH011230). None of the authors have financial, consultant, institutional, and other relation- ships that might lead to bias or a conflict of interest. Address correspondence to: Joseph G. Grzywacz, PhD, Chair and Norejane Hendrickson Professor of Family & Child Sciences, 120 Convocation Way, Tallahassee, FL 32306. (jgrzywacz@fsu.edu). Copyright ß 2019 American College of Occupational and Environmental Medicine DOI: 10.1097/JOM.0000000000001650 JOEM  Volume 61, Number 9, September 2019 735 ORIGINAL ARTICLE