Power differentials affecting workers who are undocumented or lack formal authorization to work in the U.S. can create even further structural vulnerability. Agricultural health and safety professionals and other stakeholders should engage in adapting and adopting structural competency curricula in order to increase awareness of impact of structures as well as to become better positioned to use this knowledge to improve farm worker health and well being. Healthcare providers and researchers strive to improve upon approaches to best care for farm workers and their families. Initiatives like the Migrant Health Program and Migrant Clinicians Network have made strides in increasing farm workers’ access to healthcare. However, new approaches that identify and address the structural and “social determination” of health are beginning to evolve. Among these efforts is the Structural Competency Working Group . The SCWG, based in Oakland, California, is an “inter professional group of practicing clinicians, scholars, students, and administrators from a broad range of fields, including medicine, nursing, anthropology, sociology, social work, and public health, among others. This Bay Area initiative is linked with other initiatives and networks across the U.S. and internationally. The goal of the working group, of which all this resource’s authors have been members, strawberry gutter system is to integrate structural competency into the training and practice of health care providers.” 

More information can be found on the SCWG website and on the national and international network’s website . See Figure 1. This formalization of training in structural competency and other similar frameworks could be adapted for agricultural employers, managers, supervisors, students, and agricultural health and safety practitioners. Fostering partnerships between existing structural competency experts, agricultural health and safety professionals, and community stakeholders could resolve a gap in agricultural management education and would raise awareness of structurally persistent disparities, helping to overcome challenges within the work environment, existing programs, and access to related community services. Importantly, structural competency training moves broader and deeper than most other approaches as it informs practitioners beyond individual interactions and brings historical and contemporary context to how disparities are normalized and replicated. An argument could be made that farm worker communities are becoming more experienced and established within the U.S. landscape, especially in terms of crop production and, in some cases, settlement in place as opposed to seasonal migration. However, this does not indicate or imply that their economic, political, or health conditions have improved or been rectified. According to the National Agricultural Workers Survey 2019–2020, 78% of crop farm workers identify as Hispanic; 63% are from Mexico, and 85% of all foreign-born farm workers have been in the U.S. for at least 10 years.

Many farm workers have work authorization. Half of farm workers have been with the same employer for 5 or more years, and most plan on remaining in agriculture for the majority if not all of their working years. Yet still, many farm workers face challenges in accessing healthcare, with less than half having access to health insurance. There are no national surveillance tools for farm workers engaged with livestock production, as the NAWS does not include them within their sampling frame. Although it is estimated that about 40–50% of the livestock production workforce consists of foreign-born workers, little is known about the challenges that these farm workers face. In a recent study, over 70% of cattle feed yard workers reported experiencing an occupational injury. Emergent research has documented distinct correlates for physical and mental health concerns and job characteristics that directly and indirectly impact workers. However, markers of structural and social determination of health such as immigration status, the impact of agricultural exceptionalism, ethnic segregation of labor markets , and comprehensive measures of socioeconomic status have been limited in use with farm workers, particularly in studies of livestock production workers. An approach to farm worker health must, therefore, account for the context in which the farm workers and their families live. This is not altogether unlike what structural competency training programs have done in other fields, such as medicine and public health. Many programs build upon community based approaches, but rarely reach beyond the level of the provider or specific fields of study and practicum. At its core, training in structural competency improves an individual’s ability to identify the influence of structures on health, the influences of structures on the environment in which the trainee works, generate strategies to respond to both these sets of structures, and promote a stance of humility as an approach to that other person or community. 

A parallel and hopeful trend relevant to this need for stakeholder engagement beyond healthcare, public health, and social work are the examples accumulating from individual communities and networks where more is being done to improve the well being of farm workers and their families. This is coupled with the realization that large-scale policy change is slow-moving and should not be the only lever for enacting change. For example, alliances between institutions, community-based organizations, and farm worker communities point the way for collaborative standards with leadership from farm workers that chip away at the inequities that farm workers face. These alliances have addressed structural factors by increasing wages for farm workers, including farm workers in leadership and decision-making, and providing oversight of labor practices. They address the basic human rights of farm workers in relation to working conditions, which is simultaneously changing upstream factors that determine health, injury and disease. In California, the Binational Center for the Development of Oaxacan Indigenous Communities/Centro Binacional para el Desarrollo Indígena Oaxaqueño has worked to increase enforcement of health and safety laws to protect farm workers – especially related to COVID protocols and heat-related practices . In Maine, a group of farm workers, clinicians, and designers worked together to address some of the more proximal causes of injury affecting blueberry pickers by collectively developing new rakes that led to fewer injuries while being acceptable and preferred by farm workers. Farmworker organizations, like the United Farm Workers , Pine and Farmworkers United , Familias Unidas por la Justicia , the Coalition of Immokalee Workers , and others have pushed for structural change in working conditions, living conditions, as well as inclusion in health care, drivers’ license laws and other policies. All of these factors work toward health equity by confronting and counteracting structural factors currently producing injury and disease for farm worker populations. Other examples include puentes or “bridges” programs specific to farm workers and their families’ well being. These programs align employers, community members, and migrant/immigrant workers towards improved livelihoods. Puentes programs currently exist in California, Connecticut, Minnesota, and Vermont. These industry and community partnerships support stakeholders as they take actions to improve health and work against social inequities. They are usually targeted at the level of commodity group or sometimes region, sometimes without relying on political action or legislation. These programs have a number of notable accomplishments: they have also successfully served as gatekeepers for effective injury prevention programs designed for farm workers; assisted in COVID-19 vaccine distribution and remote learning/work adaptions; and increased immigrant farm worker access to care and improved healthcare professionals’ knowledge of farm worker community. Many farm owners have found themselves in the business of managing human resources as much as producing food, fiber, and fuel. Structural change in the agricultural economy without much change in its profitability for many smaller farm owners has certainly shaped the environment in which farm owners and managers make decisions about labor. Additionally, hydroponic nft gully agricultural exemption from many labor laws and the lack of agricultural knowledge in regulatory groups have contributed to poor working conditions. Bringing farm owners and managers into the discussion about structural competency is an opportunity to continue to broaden what it means and what it takes to be a “good farmer” – in the sense that it is not just about profit margins or environmental stewardship, but also about decent work environments, where the values of “freedom, equity, security and human dignity” are intentionally fostered. Workers are more than just “hired hands” and must be treated ethically. As such, agricultural employers and managers would benefit from understanding the structural challenges farm workers face in daily life, opening the possibility of supporting farm worker communities in working toward healthier lives and thriving more generally.

Although structural interventions like comprehensive immigration reform in the U.S. and specific protections for farm workers have been discussed for many years, there has been limited change. As we work toward these changes over the long term, structural competency training and education could bring positive change to the work environment by humanizing organizational policy approaches and developing collaborative food system standards with input and leadership from farm worker communities and community-based organizations. Curriculums like that of the SCWG should be tailored for the agricultural health and safety field and redeployed. Beginning with a reframing of the core goals, a few modifications to structural competency training are needed to tailor to the agricultural context such as moving up the injury timeline from treatment to prevention, formulating approaches from worker and community perspectives rather than only healthcare practitioners and patients, and highlighting partnerships that work against power differentials between employees, community-based organizations, and employers. Training should be grounded in structural humility . If successful, the modified approach could also be impactful in agricultural management education with the possibility of even further adaptation for students at the high school level in 4 H and FFA programs. Curriculums and training are just one component of a comprehensive strategy to address the structural and social determination of health among farm workers. Farmworkers are people with unique goals and aspirations. The invisibility they experience cannot continue; this may be especially true for those that are undocumented. Society must “see” and value these workers, not only as productive labor but as human agents. As a field, we must continue to think about the systems that perpetuate inequities affecting this worker population so vital to our societies. We must work against narratives that represent these important communities as undeserving of inclusion in society. Perhaps part of the answer lays in creatively adjusting the composition of the soil in which these inequities are reproduced. Policy solutions and advocacy will be required. Previous successes in structural change impacting agricultural safety and health should be built upon. While some changes are perhaps tertiary to immigrant workers’ health and safety, some are a direct result of workers and advocates demanding change. Federal and state policy development have had profound impacts, for example, the passage of the Federal Insecticide, Fungicide, and Rodenticide ACT; the Field Sanitation Provisions; New York’s expansion of drivers’ licenses regardless of immigration status; Washington State’s worker compensation laws that require employers with even one employee to provide coverage and with no minimum hour requirement; or the development of local immigrant focused medical-legal partnerships. Industry can also make important changes; for example in 1985, when tractor manufacturers voluntarily included rollover protective structures on all models. Additionally, farm worker organizations, such as those highlighted above, must have leadership and meaningful input into the working conditions, living conditions, and societal inclusion of farm worker populations. Research has given little attention to structural and social determination of health, safety, and well being among farm workers. As such, more transdisciplinary research and interventions that incorporate these determinants and evaluate their impact are needed. Participatory approaches to research may allow for relationship building, synergies, and insights that could restructure public health practice, community engagement, and policy in the future. Some recent examples were driven by the COVID-19 pandemic, like the Coalition of Immokalee Workers working with Partners in Health to address inequalities for essential farm workers in the midst of a wildly infectious disease.36 An important concern for health professionals embracing the principles of structural competency is whether an individual care provider can impact levels beyond the individual or the family, confined by patient-seeing metrics, language, and geography. We recognize that many within the agricultural industry might question their ability to make an impact. However, sustainable social change requires intervention at multiple levels as well as engagement of various stakeholders with common goals and language. An ideal environment for initial experimentation, intervention, and evaluation could include a community with an existing puentes program or other well-connected organizations , nearby healthcare facilities that serve farm workers, community-based organizations, and the presence of adult agricultural education opportunities such as short-courses at local technical colleges. Clearly, new strategies are needed to improve farm worker well being and retain an adequate agricultural workforce.